Critical appraisal of the Portuguese clinical guideline 28/2011

Sousa-Veloso, T.

doi:10.1016/j.rppnen.2016.01.002

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Freitas, V. Lavrador, I. Coelho, R. Sousa, V. Senra, L. Morais" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A.C." "apellidos" => "Freitas" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Lavrador" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Coelho" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Sousa" ] 4 => array:2 [ "nombre" => "V." "apellidos" => "Senra" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Morais" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511515001931?idApp=UINPBA00004E" "url" => "/21735115/0000002200000003/v1_201605310123/S2173511515001931/v1_201605310123/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Research Letter" "titulo" => "Critical appraisal of the Portuguese clinical guideline 28/2011" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "181" "paginaFinal" => "182" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "T. Sousa-Veloso" "autores" => array:1 [ 0 => array:3 [ "nombre" => "T." "apellidos" => "Sousa-Veloso" "email" => array:1 [ 0 => "tiago@sousaveloso.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Neurosciences and Mental Health Department, Medical Psychology Unit, Faculty of Medicine of the University of Porto, Porto, Portugal" "identificador" => "aff0005" ] ] ] ] "textoCompleto" => "“It is not recommended the regular prescription of mucolytics nor antitussive agents.”(DGS Guideline 28/2011 - COPD, p. 5).This sentence addresses two very different therapeutic categories. We agree only with the antitussive agents part.According to the 2015 update of GOLD guidelines,<a class="elsevierStyleCrossRef" href="#bib0015">1</a> which address chronic obstructive pulmonary disease (COPD), the use of mucolytics, such as N-acetylcysteine or carbocysteine, can have a positive effect on the reduction of the number of exacerbations. The most recent Cochrane<a class="elsevierStyleCrossRef" href="#bib0020">2</a> review on the issue included many non-identical studies (a very high heterogeneity index, I2=87%), which makes it particularly difficult to identify statistically significant difference between groups. Despite this fact, the benefit reported from the use of mucolytics was significant as far as exacerbation reduction was concerned (OR 1.84; CI95% 1.63–2.07), which can also be translated into a number needing to be treated of 7 (one should treat 7 patients for at least 10 months in order to achieve a reduction of 1 exacerbation episode), as well as on the statistically significant lowering of the number of sick days (on average, a decrease of 0.48 days, CI95% −0.65 to −0.30).Following what has been said, we think that the sentence “It is not recommended the regular prescription of mucolytics nor antitussive agents.” does not reflect the real potential benefit underlying the mucolytic drugs in COPD patients, which has the additional advantage of low risk of adverse events.Therefore, we propose that the phrase quoted be replaced by sentences such as the two that follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)“The real impact of a regular prescription of mucolytic agents is still not thoroughly understood. 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Available at: <a id="intr0005" class="elsevierStyleInterRef" href="http://www.goldcopd.org/">http://www.goldcopd.org/</a>." ] ] ] 1 => array:3 [ "identificador" => "bib0020" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Poole" 1 => "P.N. Black" 2 => "C.J. 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Pulmonology

ISSN: 2531-0437

Pulmonology (previously Revista Portuguesa de Pneumologia) is the official journal of the Portuguese Society of Pulmonology (Sociedade Portuguesa de Pneumologia/SPP). The journal publishes 6 issues per year, mainly about respiratory system diseases in adults and clinical research. This work can range from peer-reviewed original articles to review articles, editorials, and opinion articles. The journal is printed in English, and is freely available in its web page as well as in Medline and other databases.

Special Issue 2023. Volume 29, Issue S4.

Indexed in:

Science Citation Index Expanded, Journal of Citation Reports; Index Medicus/MEDLINE; Scopus; EMBASE/Excerpta Medica

According to the 2015 update of GOLD guidelines,1 which address chronic obstructive pulmonary disease (COPD), the use of mucolytics, such as N-acetylcysteine or carbocysteine, can have a positive effect on the reduction of the number of exacerbations. The most recent Cochrane2 review on the issue included many non-identical studies (a very high heterogeneity index, I2=87%), which makes it particularly difficult to identify statistically significant difference between groups. Despite this fact, the benefit reported from the use of mucolytics was significant as far as exacerbation reduction was concerned (OR 1.84; CI95% 1.63–2.07), which can also be translated into a number needing to be treated of 7 (one should treat 7 patients for at least 10 months in order to achieve a reduction of 1 exacerbation episode), as well as on the statistically significant lowering of the number of sick days (on average, a decrease of 0.48 days, CI95% −0.65 to −0.30).

Following what has been said, we think that the sentence “It is not recommended the regular prescription of mucolytics nor antitussive agents.” does not reflect the real potential benefit underlying the mucolytic drugs in COPD patients, which has the additional advantage of low risk of adverse events.

Therefore, we propose that the phrase quoted be replaced by sentences such as the two that follows:

1)
“The real impact of a regular prescription of mucolytic agents is still not thoroughly understood. It should be emphasized that among COPD patients of moderate or high severity, the regular use of mucolytics (such as N-acetylcysteine of carbocystein) can have a beneficial effect on the decrease of the number of exacerbation episodes,* as well as on the reduction of the number of sick leave days.†”
2)
“We do not recommend the regular prescription of antitussive agents, as they have the potential for inhibiting the protective airway cough reflex.”

References

[1]

Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available at: http://www.goldcopd.org/.

[2]

P. Poole, P.N. Black, C.J. Cates.

Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease.

Cochrane Datab Syst Rev, (2012),

OR=1.84 (CI95% 1.63–2.07); NNT=7 (CI95% 6–9), in order to avoid one episode of exacerbation, during 10 months of continuous treatment.

†

“Average reduction of the number of sick leave days: −0.48 (CI95% −0.65 to −0.30).”

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