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Protocol for a Systematic Literature Review and Network Meta-Analysis Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2018-025048 on 20 February 2019. Downloaded from Protocol for a systematic literature review and network meta-analysis of the clinical benefit of inhaled maintenance therapies in chronic obstructive pulmonary disease Adam Lewis,1 Eleanor L Axson, 1 James Potts,1 Renelle Tarnowska,2 Helene Vioix,2 Jennifer K Quint 3 To cite: Lewis A, Axson EL, ABSTRACT Strengths and limitations of this study Potts J, et al. Protocol for a Introduction Chronic obstructive pulmonary disease systematic literature review (COPD) exacerbations progress the course of disease and ► The planned systematic literature review and and network meta-analysis of impair lung function. Inhaled maintenance therapy reduces the clinical benefit of inhaled network meta-analysis will evaluate both ran- exacerbations. It is not yet established which inhaled maintenance therapies domised controlled trials and real-world evidence therapy combination is best to reduce exacerbations, lung in chronic obstructive in order to reflect the current best evidence-based function decline and symptom burden. pulmonary disease. BMJ Open practice and increase the application to a potentially Methods and analysis MEDLINE, EMBASE and the 2019;9:e025048. doi:10.1136/ heterogeneous group of patients with COPD. bmjopen-2018-025048 Cochrane Library will be searched for articles between ► A ranking system of all inhaled treatment compari- January 2011 and May 2018 using a pre-specified search Prepublication history for sons will enable clinicians to judge each intervention ► strategy. Conference proceedings will be searched. this paper is available online. on their evidence of clinical benefit compared with Systematic reviews (with or without meta-analysis), To view these files, please visit their potential harms. randomised controlled trials (RCTs), cohort studies and the journal online (http:// dx. doi. ► It may not be possible to combine both randomised case controlled studies comparing six interventions org/ 10. 1136/ bmjopen- 2018- controlled trials and other study designs in a single comprising different combinations of long-acting 025048). network meta-analysis. bronchodilators and inhaled corticosteroids in unison or Received 27 June 2018 on their own. The primary outcome is the reduction in http://bmjopen.bmj.com/ Revised 6 November 2018 moderate-to-severe exacerbations. Secondary outcomes Accepted 29 January 2019 include: lung function, quality of life, mortality and other smoking, and patients exhibit airflow obstruc- adverse events. Titles and abstracts will screened by the tion that is not fully reversible. The disease primary researcher. A second reviewer will repeat this is progressive, with declining lung function on a proportion of records. The Population, Intervention, and a worsening of symptoms. Most trouble- Comparator, Outcomes and Study framework will be used some are acute exacerbations manifested as a for data extraction. A network meta-analyses of outcomes sudden worsening of symptoms, for example, from RCTs and real-world evidence will be integrated if severe coughing, shortness of breath and on September 26, 2021 by guest. Protected copyright. © Author(s) (or their feasible. The 95% credible interval will be used to assess employer(s)) 2019. Re-use the statistical significance of each summary effect. chest congestion, requiring urgent treat- permitted under CC BY-NC. No Ranking of interventions will be based on their surface ment and possibly hospitalisation. While commercial re-use. See rights smoking cessation remains the most effec- and permissions. Published by under cumulative ranking area. BMJ. Ethics and dissemination COPD exacerbations are tive intervention, the rate of exacerbation 1Department of Respiratory burdensome to patients. We aim to report results that can be reduced by regular medication such Epidemiology, National Heart provide clinicians with a more informed choice of as combination of long-acting beta-adreno- 2 and Lung Institute, Imperial which inhaled therapy combinations are best to reduce ceptor agonists (LABAs), and inhaled corti- College London, London, UK exacerbations, improve disease burden and reduce lung costeroids (ICS)3 4 or long-acting muscarinic 2 Boehringer Ingelheim Ltd, function and exercise capacity decline, compared with the antagonists (LAMAs).5 Bracknell, UK potential harms, in certain populations with COPD. 3 COPD treatment guidelines are largely Department of Respiratory PROSPERO registration number CRD42018088013. Epidemiology, Occupational informed by randomised controlled trial 6 Medicine and Public Health, (RCT) results, but we do not know if these Imperial College London, BACKGROUND findings apply to large patient populations London, UK Rationale not studied in trials. While RCTs will continue Correspondence to Chronic obstructive pulmonary disease to be the gold standard for assessing the effi- Dr Adam Lewis; (COPD) affects around 174 million persons cacy of medical interventions, they are expen- adam. lewis@ imperial. ac. uk worldwide.1 The most common cause is sive to conduct, and for practical and ethical Lewis A, et al. BMJ Open 2019;9:e025048. doi:10.1136/bmjopen-2018-025048 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-025048 on 20 February 2019. Downloaded from reasons usually involve testing treatments in patient combinations in COPD described by RCTs and real- populations and within contexts which are sometimes world evidence (RWE) studies. A network meta-analyses very different from real life. In particular, RCT partici- of outcomes from RCTs and RWE will be integrated if pants with COPD usually have no comorbidities and are feasible. otherwise healthy. Whereas often the very patients who The primary research question is: What are the clin- are most commonly seen in a COPD outpatient clinic are ical benefits of maintenance treatment combinations in those that would be excluded from clinical trials due to COPD in terms of reducing exacerbations? their comorbidities. As patient populations with chronic Secondary research questions include: diseases such as COPD become more complex, the studies 1. What is the long-term effectiveness of treatment com- used to generate clinical evidence must reflect this. binations on improving lung function as measured by Evidence of medication effects in routine care is vital forced expiratory volume in 1 s (FEV1)? for understanding the balance of treatment risks and 2. What is the long-term effectiveness of treatment com- benefits. RCTs have unique strengths, but results from binations in improving patient-reported outcomes of trials are not always a good guide to the effects of drugs in respiratory-related quality of life, as measured by the routine clinical practice.7 National drug licensing author- St Georges Respiratory Questionnaire or the COPD ities are now demanding better real-world evidence on Assessment Test? which to make decisions and have introduced legislation 3. What are the harms of each treatment combination in- mandating studies of both effectiveness and risk to be cluding mortality, cardiovascular events, pneumonia, conducted in routine clinical care rather than the narrow diabetes and bone fractures? and optimal confines of most randomised trials.8 9 While the conduct of observational studies to investigate METHODS possible drug harms is well established, the use of these This protocol has been prepared using the Preferred studies to estimate treatment effectiveness is in its infancy. Reporting Items for Systematic Reviews and Meta-Anal- Issues of treatment channelling and indication bias mean yses Protocols guidelines.18 that measuring the intended benefit of a treatment is beset with difficulties. While others have demonstrated Eligibility criteria it can be done in certain circumstances, we need more Study design/characteristics certainty about the methodology as it is applied in each Target studies will include RCTs, cohort studies and case– disease area, since the issues of bias are likely to vary 9 control studies comparing each intervention of interest considerably. to any of the possible comparators and looking at any of There is increasing evidence that dual long-acting bron- the possible outcomes (see below and table 1). We will chodilator therapy (LABA+LAMA) is more clinically bene- 10 also use summary papers, systematic reviews and other ficial compared with monotherapy or placebo ; however, analyses to source relevant primary papers. http://bmjopen.bmj.com/ there is also evidence that adding an ICS to LABA and LABA as triple therapy is better at reducing exacerbations Participants 11 and maintaining lung function. Furthermore, new treat- Adults diagnosed with COPD defined by a fixed post-bron- ments for reducing exacerbation frequency have become chodilator ratio of forced expiratory volume in 1 s to more evidenced based in recent years with commonly forced vital capacity (FEV1/FVC) of less than 0.70. Other inhaled therapies (LABAs, LAMAs, ICS and combination measures of impaired lung function, such as lower limit devices) being prescribed alongside other treatments 12 of normal of FEV1/FVC ratio, will not be used to judge such as mucolytics (carbocysteine, N-acetylcysteine), diagnosis in this review. The population will be clinically on September 26, 2021 by guest. Protected copyright. antibiotics (macrolides) and inhaled colomycin13 14 and 15 stable at the time of recruitment, defined as not having phosodiesterase-4 inhibitors such as roflumilast.
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