EVIDENCE BASED MEDICINE- LIST

 1. Gastro - Oesophageal Reflux Disease- (GORD)                                                         

 2. Heart Failure

3.Stroke Prevention

4. Post-Herpetic Neuralgia

5. Generalised Anxiety Disorder (GAD)

6. Depression

7.Premenstrul Syndrome (PMS)

                           EVIDENCE BASED MEDICINE-(ref.MIMS)

                  1. Gastro-Oesophageal Reflux Disease- (GORD)

              Comparative effectiveness of various interventions

Beneficial-                                                                                                                               o Proton Pump Inhibitors such as Omeprazole, Lansoprazole, Pantoprazole                     o H-2 Antogonists such as Cimetidine, Ranitidine, Famotidine,(less effective than                 proton pump inhibitors)                                                                                                    o Fundaplication

Likely to be Beneficial                                                                                                       o Medical and surgical treatment of GORD in selected patients with extra-oesophageal        manifestations

Unknown effectiveness                                                                                                     o Medical  and surgical treatment of GORD in patients with Barrett’s oseophagus           o Surgical treatment for non-erosive oesophagitis

Key Points                                                                                                                     o One system review of randomised clinical trials has found proton pump inhibitors to          be more effective than   H2-antagonists in both erosive and non-erosive oesophagitis.     One trial has found no significant difference in the effectiveness of different proton           pump inhibitors                                                                                                            o Surgical treatment has not been adequately evaluated in controlled clinical trials.             Medical and surgical treatments have not been adequately compared.                            o It is not clear whether patients with Barrett’s oesophagus benefit from medical or                surgical treatment of their gastro-intestinal reflux.                                                     o There is limited, conflicting evidence on the benefits of treating gastro-oesophageal        reflux in patients with extra-oesophageal manifestations (such as asthma)

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                           EVIDENCE BASED MEDICINE-(ref.MIMS)

                                              2. Heart Failure

                      Comparative effectiveness of Various Interventions

Beneficial 

 o  Ace inhibitors such as Captopril,Enalapril,Lisonopril and Perindopril                               o  Digoxin                                                                                                                           o   Appropriate use of Beta-blockers                                                                                   o  Spronolactone in severe cases

Likely to be beneficial

  o  Multidisciplinary interventions (nutrition,counselling )                                                      o  Angiotensin II receptor blockers                                                                                    o   Amidarone                                                                                                                  o   Implantable cardiac defibrillators

Unlikely to be beneficial

o  Calcium Channel Blockers   

Likely to be ineffective or harmful

 o  Positive inotropes (non-digitalis)                                                                                       o  Non- amidarone antiarryhthmic drugs

Key Points

 o  There is conflicting evidence on the efficacy of multi-disciplinary approach                     o   Prescribed excercise training  improves functional capacity and quality of life and              reduces rate of adverse cardiac events                                                                       o   Ace imhibitors reduce mortality, admission to hospital for heart failurein patients with        heart failure but are still under-used                                                                             

 o  One clinical trial has found that angiotensin II  receptor blockers are at least as                 effective as ACE inhibitors for reducing clinical events (death or admission to                     hospital).                                                                                                                               They confer no advantage over ACE Inhibitots, but can be useful if ACE inhitors are         not tolerated.                                                                                                               

 o  Positive inotropic drugs improve symtoms but do not reduce mortality                       o  Adding a  betablocker to ACE inhibitors are not tolerated                                             o   Positive inotropic drugs imorive symtoms but do not reduce mortality                         

 o   Adding a Beta-blocker to ACE inhibitors decreases the rate of death admission to             hospitals.                                                                                                                         o   One clinical trial has found that in severe heart failure, adding an aldersterone                  receptor  antagonist to an ACE inhibitor reduces mortality compared with ACE                  inhibitors alone                                                                                                             

o   ACE inhibitor delays the onset of symptoms and reduce cardiovascular events in              patients with asymtopmatic left  ventricular systolic dysfunction

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                                   EVIDENCE BASED MEDICINE

                                     3.STROKE PREVENTION

                     Comparative effectiveness of various intervention

 PRIOR TO STROKE OR TRANSIENT ISCHEMIC ACCIDENT (TIA)

Beneficial

• Antiplatelet treatment   
•  Cholesterol reduction (for those patients who also have coronary heart disease)   
•   Carotid endarterectomy (in patients with severe symptomatic carotid artery stenosis)

Unknown effectiveness 

• Cholesterol reduction (for Patients without CHD)        
• Blood pressure reduction      
• Carotid endarterectomy (in patients with severe asymptomatic carotid artery stenosis) 
• Carotid angioplasty                                                                                                                                                                                                                 

Likely to be ineffective or even harmful

• Oral anti-coagulation                                                                                                                                                                                                                 

ATRIAL FIBRILATION AND A PRIOR STROKE OR TIA

Beneficial

•  Oral Anti-coagulation 
•  Aspirin for patients with contraindication to an anticoagulant                                                                                                                                                                                                            

ATRIAL FIBRILLATION BUT NO OTHER MAJOR RISK FACTORS FOR STROKE

 Likely to be beneficial 

•  Oral Anti-coagulation 
•  Aspirin for patients with contraindication to an anticoagulant                                                                                                                                                                                                     

KEY POINTS

In patients with prior stroke or TIA  

• Insufficient evidence to support routine blood pressure reduction  
• Statins may prevent stroke in those with a history of CHD but evidence inconclusive                                                          in those with no history of CHD
• Routine use of prolonged anti-platelet treatment beneficial (if no contraindication) 
• Aspirin 7mg daily as effective as higher doses. No evidence that other antiplatelet  regimen is definitely superior in the prevention of vascular events. Clopidogrel or the combination of aspirin and dipyridamole are safe and effective (but more costly) alternatives to aspirin.        
• No evidence of benefit from anti-coagulation in patients in sinus rhythm, but an increased risk of serious bleeding  
•  Carotid endarterectomy reduces risk of major stroke in patients with severe carotid stenosis provided the risks of imaging and surgery  are small    
• Percutaneous transluminal angioplasty’s role has not been evaluated adequately

 In patients with atrial fibrillation and proper stroke of TIA    

• Anticoagulants reduces risk of stroke, provided there is low risk of bleeding and careful monitoring
• Aspirin reduces risk of stroke but less effectively than anticoagulants. These findings support the use of Aspirin among patients with  atrial fibrillation and contraindication to anticoagulants

  In Patients with atrial fibrillation but neither major risk factors of stroke   

• Anticoagulants are of benefit, if low risk of bleeding and careful monitoring 
• Aspirin is a reasonable alternative in patients with contraindications to anticoagulants          

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                                 EVIDENCE BASED MEDICINE

                               4. POST-HERPETIC NEURALGIA

                         Comparative effectiveness of various intervention

 PREVENTION OF POST-HERPETIC NEURALGIA

Beneficial

•    Oral antiviral agents such as Acyclovir, Famciclovir, Valaciclovir,                  Netivudine  
•     Tricyclic antidepressants(amitriptyline)     
•     Topical agents (short-term pain relief)                                                                                                                                                                                                                                                 

Unknown effectiveness  

•  Levodopa                     
•  Amantadine  
• Isoprinosine
• Adenosine monophosphate                                                                                                                                                                                                                                                                                                                                                                                                                

Likely to be ineffective or even harmful

• Topical antiviral agents (Idoxuridine) for relief of acute pain only   
• Cimetidine                                                                                                                                                                                                  

Ineffective or Harmful

• Corticosteroids                                                                                                                                

RELIEVING ESTABLISHED POST-HERPETIC NEURALGIA

Beneficial

• Tricyclic antidepressants (Amitriptyline)                                                                                                                                         
• Oxycodone (Opioid) 
• Gabapentin (anti-convulsant)                                                                                                                                                 

Unknown effectiveness   

• Capsaicin (topical counterirritant
•  Topical lignocaine                                                                                                                        

Ineffective or Harmful

                Epidural morphine

•  Dextromethorphan 

                                         KEY POINTS

• Daily acyclovir reduced the relative risk of post-herpetic pain at six months by about 50 percent compared with placebo
• Famciclovir significantly reduced pain duration after acute herpes zoster   
• Idoxuridine was associated with short term pain relief in acute herpes zoster but did not prevent post-herpetic neuralgia   
• Conflicting evidence on whether corticosteroids alone prevent post-herpetic neuralgia. Limited evidence that high dose steroids and anti-viral agents combined may speed healing herpes-zoster. No evidence that it reduces post-herpetic neuralgia     
• Amitriptyline started during acute episode reduced prevalence of post herpetic neuralgia at six months 
• Insufficient evidence on the effects of other treatments                                                                                                                                                      

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                                    EVIDENCE BASED MEDICINE

                           5. GENERALISED ANXIETY DISORDER (GAD)

                    Comparative effectiveness of various interventions

       Definition  

• Excessive worry and tension, on most days, or at least for six months
• With increased motor tension, fatiguability, trembling, restlessness, muscle tension   
• With automatic hyperacidity -shortness of breath, rapid heart rate, dry mouth, cold hands, and dizziness but not panic attacks 
• With increased vigilance and scanning -feeling keyed up, increased starting, impaired concentration

Beneficial

•  Cognitive therapy

Likely to be beneficial

• Buspirone
• Certain antidepressants (paroxetine, imipramine, trazadone, venlafaxine)

Trade-off between benefits and harms

• Benzodiazepines 

Unknown effectiveness

• Anti-psychotic drugs
• Betablockers                                                                                                                                                     

                                                               KEY POINTS

• A systemic review of randomised clinical trials (RCTs) has found cognitive therapy with behavioural intervention is more effective than no treatment, anxiety management training alone, or non-directive therapy. No adverse effects were noticed
• One systemic review of randomised clinical trials (RCTs) has found that benzodiazepines are an effective and rapid treatment for generalised anxiety disorder. One RCT found no significant in the effects of slow-release alprazolam and bromazepam.
• RCTs have found that buspirone is effective in GAD. Slower onset compared with benzodiazepines is counter-balanced by fewer side effects
• RCTs have found that imipramine, trazadone, venlafaxine and paroxetine are effective treatments for GAD. One trial found that paroxetine was more effective than benzodiazepines. There is a significant risk of side effects with these drugs.
• One RCT in people with GAD fund that trifluoperazine was effective in low dose but carried significant risk of serious side effects
• It was found that beta-blockers had not been adequately evaluated in GAD

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                                    EVIDENCE BASED MEDICINE

                                              6. DEPRESSION

                    Comparative effectiveness of various interventions

       Beneficial

• Tricyclic and heterocyclic antidepressants
• Selective serotonin uptake inhibitors and related drugs 
• Monoamine oxidase inhibitors
• Cognitive therapy (mild to moderate depression)
• Interpersonal therapy mild to moderate depression)

Likely to be beneficial

• St. John’s wort in mild to moderate depression
• Problem solving therapy in mild to moderate depression
• Combining drug and psychological treatment in severe depression
• Maintenance drug treatment may prevent recurrence

Unknown effectiveness

• Exercise
• Bibliotherapy (advising patients to read material on mood therapy)
• Non-directive counselling
• Psychological treatment in severe depression
• Clinician collaboration and patient education

                                                KEY POINTS

• Several treatments are effective in the treatment of mild to depression. These include anti-depressant drugs, cognitive therapy and interpersonal therapy. Less robust RCTs have found that problem solving therapy and St. John’s wort are also effective. Specific psychological treatments such as cognitive and interpersonal therapy have shown to be as effective as drugs, and there is no clinically significant difference between anti-depressant drugs, although they vary in adverse effects and costs
• There is limited evidence that other treatments such as exercise, bibliotherapy and non-directive counselling may be effective, but further research is needed
• There is no reliable evidence that one type of treatment (drug or non-drug) is superior to another. Limited evidence suggests that combing drug and psychological treatments may be effective but not in mild to moderate depression
• Of the interventions examined, anti-depressants drugs are the only treatment for which there is a good evidence of effectiveness in severe and psychotic depressive disorders. There are no trials comparing drug and non-drug treatments in severe depressive disorder
• Continuing anti-depressant drug treatment for four to six months after recovery reduces the risk of relapse, and maintenance therapy in recurrent depressive disorder reduces the risk of recurrence
• There is no evidence of a difference in long term benefits between treatments

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                                     EVIDENCE BASED MEDICINE

                             7.PREMENSTRUAL SYNDROME (PMS)

                    Comparative effectiveness of various interventions

       Beneficial   

       Overall Premenstrual Syndrome Symptoms

•   Prostaglandin inhibitors ( eg.  Indomethacin)      
•  Selective Serotonin Reuptake Inhibitors (eg. Fluoxetine, Sertraline, Fluvoxamine)

 Breast symptoms only

•  Luteal phase- danazol
• Bromocriptine

Bloatedness and swelling

• Tibolones
• Oestrogen
• Vitamin B-6
• Evening primrose oil
• Exercise

Trade off between Benefits and Harm

• Danazol
• Gonadotrophin -releasing hormone (GnRH analogues)
• Non-SSRI antidepressants/anxiolytics
• Hysterectomy with/without oophorectomy

Unknown Effectiveness

• Progesterone
• Progestogens
• Oral contraceptives
• Cognitive behavioural treatment
• Dietary supplements
• Relaxation treatment
• Endometrial ablation
• Laproscopic bilateral oophorectomy

Key Points

• Trials have found that SSRIs and prostaglandin inhibitors relieve premenstrual symptoms. Antidepressants and ovulation suppression with danazol and GNRH analogues are also effective but have significant adverse effects, including the masculanising effects of danazol and the menopausal effects of GnRH analogues
• There is a limited evidence suggesting that oestrogen, Vitamin B-6, Evening Primrose Oil and exercise may be beneficial

• Trials have found that bromocriptine is effective for breast symptoms and diuretics are effective for bloatedness and swelling. Both can have adverse effects
• There is no good evidence to support the use of progesterone or oral contraceptives
• Few treatments have been adequately validated in trials

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