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Protease-Modulating Matrix Treatments for Healing Venous Leg Ulcers (Review)

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Protease-Modulating Matrix Treatments for Healing Venous Leg Ulcers (Review) Cochrane Database of Systematic Reviews Protease-modulating matrix treatments for healing venous leg ulcers (Review) Westby MJ, Norman G, Dumville JC, Stubbs N, Cullum N Westby MJ, Norman G, Dumville JC, Stubbs N, Cullum N. Protease-modulating matrix treatments for healing venous leg ulcers. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD011918. DOI: 10.1002/14651858.CD011918.pub2. www.cochranelibrary.com Protease-modulating matrix treatments for healing venous leg ulcers (Review) Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . ..... 4 BACKGROUND .................................... 6 OBJECTIVES ..................................... 8 METHODS ...................................... 8 Figure1. ..................................... 11 Figure2. ..................................... 14 Figure3. ..................................... 15 RESULTS....................................... 18 DISCUSSION ..................................... 23 AUTHORS’CONCLUSIONS . 24 ACKNOWLEDGEMENTS . 25 REFERENCES ..................................... 25 CHARACTERISTICSOFSTUDIES . 33 DATAANDANALYSES. 63 Analysis 1.1. Comparison 1 PPM dressing regimen versus other dressing regimen, Outcome 1 Proportion of participants healed(shortterm-8weeks). 64 Analysis 1.2. Comparison 1 PPM dressing regimen versus other dressing regimen, Outcome 2 Proportion of participants healed(mediumterm-12weeks).. 65 Analysis 1.3. Comparison 1 PPM dressing regimen versus other dressing regimen, Outcome 3 Proportion of participants with 1 or more adverse events at 2-12 weeks. ....... 66 Analysis 1.4. Comparison 1 PPM dressing regimen versus other dressing regimen, Outcome 4 Proportion of participants withpainat2-12weeks. 67 Analysis 1.5. Comparison 1 PPM dressing regimen versus other dressing regimen, Outcome 5 Proportion of participants withinfectionat2-12weeks. 68 Analysis 1.6. Comparison 1 PPM dressing regimen versus other dressing regimen, Outcome 6 Sensitivity analysis - available case - proportion of participants healed. ........ 69 Analysis 1.7. Comparison 1 PPM dressing regimen versus other dressing regimen, Outcome 7 Subgroup analysis: (+/-) silver - proportion of participants healed medium term. ............... 70 ADDITIONALTABLES. 71 APPENDICES ..................................... 76 WHAT’SNEW..................................... 82 CONTRIBUTIONSOFAUTHORS . 82 DECLARATIONSOFINTEREST . 82 SOURCESOFSUPPORT . 83 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . .... 83 INDEXTERMS .................................... 84 Protease-modulating matrix treatments for healing venous leg ulcers (Review) i Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Review] Protease-modulating matrix treatments for healing venous leg ulcers Maggie J Westby1, Gill Norman1, Jo C Dumville1, Nikki Stubbs2, Nicky Cullum1 1Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK. 2Wound Prevention and Management Service, Leeds Community Healthcare NHS Trust, St Mary’s Hospital, Leeds, UK Contact address: Maggie J Westby, Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK. [email protected]. Editorial group: Cochrane Wounds Group. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2017. Citation: Westby MJ, Norman G, Dumville JC, Stubbs N, Cullum N. Protease-modulating matrix treatments for healing venous leg ulcers. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD011918. DOI: 10.1002/14651858.CD011918.pub2. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Venous leg ulcers (VLUs) are open skin wounds on the lower leg that occur because of poor blood flow in the veins of the leg; leg ulcers can last from weeks to years, and are both painful and costly. Prevalence in the UK is about 2.9 cases per 10,000 people. First- line treatment for VLUs is compression therapy, but around 60% of people have unhealed ulcers after 12 weeks’ treatment and about 40% after 24 weeks; therefore, there is scope for further improvement. Limited evidence suggests non-healing leg ulcers may have persisting elevated levels of proteases, which is thought to deter the later stages of healing; thus, timely protease-modulating matrix (PMM) treatments may improve healing by physically removing proteases from the wound fluid. Objectives To determine the effects of protease-modulating matrix (PMM) treatments on the healing of venous leg ulcers, in people managed in any care setting. Search methods In September 2016 we searched: the Cochrane Wounds Specialised Register; CENTRAL; Ovid MEDLINE; Ovid MEDLINE (In- Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria We searched for published or unpublished randomised controlled trials (RCTs) that evaluated PMM treatments for VLUs. We defined PMM treatments as those with a purposeful intent of reducing proteases. Wound healing was the primary endpoint. Data collection and analysis Two review authors independently performed study selection, risk of bias assessment and data extraction. Protease-modulating matrix treatments for healing venous leg ulcers (Review) 1 Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Main results We included 12 studies (784 participants) in this review; sample sizes ranged from 10 to 187 participants (median 56.5). One study had three arms that were all relevant to this review and all the other studies had two arms. One study was a within-participant comparison. All studies were industry funded. Two studies provided unpublished data for healing. Nine of the included studies compared PMM treatments with other treatments and reported results for the primary outcomes. All treatments were dressings. All studies also gave the participants compression bandaging. Seven of these studies were in participants described as having ’non-responsive’ or ’hard-to-heal’ ulcers. Results, reported at short, medium and long durations and as time-to- event data, are summarised for the comparison of any dressing regimen incorporating PMM versus any other dressing regimen. The majority of the evidence was of low or very low certainty, and was mainly downgraded for risk of bias and imprecision. It is uncertain whether PMM dressing regimens heal VLUs quicker than non-PMM dressing regimens (low-certainty evidence from 1 trial with 100 participants) (HR 1.21, 95% CI 0.74 to 1.97). In the short term (four to eight weeks) it is unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (very low-certainty evidence, 2 trials involving 207 participants). In the medium term (12 weeks), it is unclear whether PMM dressing regimens increase the probability of healing compared with non- PMM dressing regimens (low-certainty evidence from 4 trials with 192 participants) (RR 1.28, 95% CI 0.95 to 1.71). Over the longer term (6 months), it is also unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (low certainty evidence, 1 trial, 100 participants) (RR 1.06, 95% CI 0.80 to 1.41). It is uncertain whether there is a difference in adverse events between PMM dressing regimens and non-PMM dressing regimens (low-certainty evidence from 5 trials, 363 participants) (RR 1.03, 95% CI 0.75 to 1.42). It is also unclear whether resource use is lower for PMM dressing regimens (low-certainty evidence, 1 trial involving 73 participants), or whether mean total costs in a German healthcare setting are different (low-certainty evidence, 1 trial in 187 participants). One cost-effectiveness analysis was not included because effectiveness was not based on complete healing. Authors’ conclusions The evidence is generally of low certainty, particularly because of risk of bias and imprecision of effects. Within these limitations, we are unclear whether PMM dressing regimens influence venous ulcer healing relative to dressing regimens without PMM activity. It is also unclear whether there is a difference in rates of adverse events between PMM and non-PMM treatments. It is uncertain whether either resource use (products and staff time) or total costs associated with PMM dressing regimens are different from those for non- PMM dressing regimens. More research is needed to clarify the impact of PMM treatments on venous ulcer healing. PLAIN LANGUAGE SUMMARY Protease-modulating matrix treatments for healing venous leg ulcers Review question We reviewed the evidence about the effects of treatments designed to lower the levels of protease in venous leg ulcers. Protease is an enzyme,
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