Yang TX et al, 2017: A network meta-analysis on the beneficial effect of medical expulsive therapy after extracorporeal shock wave lithotripsy.
Yang TX, Liao BH, Chen YT, Li H, He Q, Liu QY, Wang KJ.
Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China.
Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P. R. China.
We applied a newly introduced method, network meta-analysis, to re-evaluate the expulsion effect of drugs including tamsulosin, doxazosin, nifedipine, terazosin and rowatinex after extracorporeal shock wave lithotripsy (ESWL) as described in the literature. A systematic search was performed in Medline, Embase and Cochrane Library for articles published before March 2016. Twenty-six studies with 2775 patients were included. The primary outcome was the number of patients with successful stone expulsion. The data were subdivided into three groups according to duration of follow-up. A standard network model was established in each subgroup. In 15-day follow-up results, SUCRA outcome showed the ranking of effects was: doxazosin > tamsulosin > rowatinex > nifedipine > terazosin (88.6, 77.4, 58.6, 32.2 and 30.4, respectively). In 45-day follow-up results, SUCRA ranking was: tamsulosin > nifedipine > rowatinex (69.4, 67.2 and 62.6, respectively). In 90-day follow-up results, SUCRA ranking was: doxazosin > rowatinex > tamsulosin (84.1, 68.1 and 49.1, respectively). In conclusion, doxazosin and tamsulosin have potential to be the first choice for pharmacological therapy to promote the expulsion of urinary stone fragments after ESWL, with this doxazosin can improve the SFR in the long term, while tamsulosin may result more in accelerating the process of expulsion.
Sci Rep. 2017 Oct 31;7(1):14429. doi: 10.1038/s41598-017-14862-3. FREE ARTICLE
Network metaanalysis is the new kid on the block.
The present authors looked at 26 studies with 5 interventions (tamsulosin, terazosin, doxazosin, nifedipine and Rowatinex) compared with placebo or non-placebo on a total of 2775 patients. They offer a very detailed conclusion with a saddening end: “The current network meta-analysis demonstrated that tamsulosin, doxazosin, nifedipine and rowatinex are effective for promoting the expulsion of urinary stone fragments after ESWL, of which α-adrenoceptor antagonists are better than calcium channel blockers, especially at a short expulsion time. Among three types of α-adrenoceptor antagonists, doxazosin can improve the SFR after ESWL in the long term, while tamsulosin may result more in accelerating the process of expulsion after ESWL, but terazosin did not show any efficacy, at least in the existing literature. Therefore, doxazosin and tamsulosin have the potential to be considered as the first choices of pharmacological therapy to improve SFR after ESWL, although more high-quality RCTs will be needed to evaluate the efficacy and reliability of doxazosin compared with tamsulosin.”
Sridharan K and Sivaramakrishnan G claimed to have published the first network meta-analysis on that topic: (Sridharan K, Sivaramakrishnan G. Medical expulsive therapy in urolithiasis: a mixed treatment comparison network meta-analysis of randomized controlled clinical trials. Expert Opin Pharmacother. 2017 Aug 4:1-11)
They analyzed 103 studies with 18,319 participants. Their conclusion was less differentiated but had a similar end:
“We observed a statistically significant increase in the expulsion rate and shorter expulsion time with alpha blockers, PDEI, and combined alpha blockers with corticosteroids. Of these, alpha blockers could be the best intervention. However, the same classes of drugs were also associated with an increased risk of adverse events. The quality of evidence is moderate for the recommendations pertaining to alpha blockers and very low for other drugs used in MET.”
After looking at the treatment results of > 18000 patients it is still all statistics and more to come.
Who will be able to stop standard clinical research on that topic?