Research Letter
Critical appraisal of the Portuguese clinical guideline 28/2011
T. Sousa-Veloso
Neurosciences and Mental Health Department, Medical Psychology Unit, Faculty of Medicine of the University of Porto, Porto, Portugal
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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" => "<span class="elsevierStyleTextfn">Research Letter</span>" "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" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">“It is not recommended the regular prescription of mucolytics nor antitussive agents.”</p><span class="elsevierStyleSource">(DGS Guideline 28/2011 - COPD, p. 5).</span></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">This sentence addresses two very different therapeutic categories. We agree only with the antitussive agents part.</p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the 2015 update of GOLD guidelines,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">1</span></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"><span class="elsevierStyleSup">2</span></a> review on the issue included many non-identical studies (a very high heterogeneity index, <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>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; CI<span class="elsevierStyleInf">95%</span> 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, CI<span class="elsevierStyleInf">95%</span> −0.65 to −0.30).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Following what has been said, we think that the sentence “<span class="elsevierStyleItalic">It is not recommended the regular prescription of mucolytics nor antitussive agents.”</span> 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.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleLabel">1)</span><p id="par0030" class="elsevierStylePara elsevierViewall">“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,<a class="elsevierStyleCrossRef" href="#fn0005"><span class="elsevierStyleSup">*</span></a> as well as on the reduction of the number of sick leave days.<a class="elsevierStyleCrossRef" href="#fn0010"><span class="elsevierStyleSup">†</span></a>”</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0035" class="elsevierStylePara elsevierViewall">“We do not recommend the regular prescription of antitussive agents, as they have the potential for inhibiting the protective airway cough reflex.”</p></li></ul></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.84 (CI<span class="elsevierStyleInf">95%</span> 1.63–2.07); NNT<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7 (CI<span class="elsevierStyleInf">95%</span> 6–9), in order to avoid one episode of exacerbation, during 10 months of continuous treatment.</p>" "identificador" => "fn0005" ] 1 => array:3 [ "etiqueta" => "†" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">“Average reduction of the number of sick leave days: −0.48 (CI<span class="elsevierStyleInf">95%</span> −0.65 to −0.30).”</p>" "identificador" => "fn0010" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:2 [ 0 => array:3 [ "identificador" => "bib0015" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. 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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