泰国玛希隆大学Ammarin Thakkinstian团队对惊恐障碍伴或不伴广场恐怖症的药物治疗进行了系统回顾和荟萃分析。2022年1月19日出版的《英国医学杂志》发表了这项成果。
为了在伴或不伴广场恐怖症的惊恐障碍治疗中，筛选出具有高缓解率和低不良事件风险的药物类别和个体选择性5-羟色胺再摄取抑制剂（SSRI），研究组在Embase、Medline和ClinicalTrials.gov数据库中检索截至2021年6月17日的文献，并进行系统回顾和荟萃分析。
符合标准的随机对照试验包括被诊断为惊恐障碍的≥18岁的成年人，比较用于治疗惊恐障碍的药物，并测量相关结果，包括缓解、退出和不良事件。纳入研究中的偏倚风险使用随机试验中修订的Cochrane偏倚风险工具进行评估。采用随机效应模型进行直接荟萃分析。采用累积排名曲线下曲面（SUCRA）的两阶段网络荟萃分析评估药物类别和个体SSRI的疗效。
符合入选条件的87项研究共包括12800名参与者和12种药物类别。几乎所有研究（86/87）都有一些利害关系或存在高偏倚风险。缓解的网络荟萃分析与相应的结果表明，三环类抗抑郁药、苯二氮卓类、单胺氧化酶抑制剂、SSRIs和5-羟色胺-去甲肾上腺素再摄取抑制剂（SNRIs）与显著高于安慰剂的缓解率相关，风险比分别为1.39、1.47、1.30、1.38和1.27。
SUCRAs将苯二氮卓类（84.5%，平均等级2.4）、三环类抗抑郁药（68.7%，3.8）和SSRIs（66.4%，4.0）确定为缓解的前三最佳治疗药物。然而，与安慰剂相比，三环类抗抑郁药、苯二氮卓类和SSRIs也与不良事件风险增加显著相关，风险比分别为1.79、1.76和1.19。
不良事件的一致性假设得到了支持，但在删除高比例女性参与者和广场恐怖症患者的研究时仍然存在。考虑所有药物类别中缓解和不良事件的SUCRA聚类排序图表明，SSRIs与高缓解和低不良事件风险相关。在个体SSRI中，舍曲林和艾司西酞普兰的病情缓解率高，不良事件风险可接受。
研究结果表明，SSRIs为惊恐障碍的治疗提供了高缓解率和低不良事件风险。在SSRI中，舍曲林和艾司西酞普兰与高缓解率和低不良事件风险相关。然而，由于研究内的偏倚、不一致性和报告结果的不精确性，研究结果大多基于中等至极低证据确定性水平的研究。
附：英文原文
Title: Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials
Author: Natasha Chawla, Thunyarat Anothaisintawee, Kridsada Charoenrungrueangchai, Papan Thaipisuttikul, Gareth J McKay, John Attia, Ammarin Thakkinstian
Issue&Volume: 2022/01/19
Abstract:
Objective To identify drug classes and individual selective serotonin reuptake inhibitors (SSRIs) with high rates of remission and low risk of adverse events in the treatment of panic disorder with or without agoraphobia.
Design Systematic review and network meta-analysis.
Data sources Embase, Medline, and ClinicalTrials.gov from inception to 17 June 2021.
Eligibility criteria for study selection Randomised controlled trials that included adults aged ≥18 years with a diagnosis of panic disorder, compared drugs used to treat the panic disorder, and measured the outcomes of interest, including remissions, dropouts, and adverse events.
Methods Risk of bias in the included studies was assessed using the revised Cochrane risk of bias tool for randomised trials. Direct meta-analyses were performed using random effects models. A two stage network meta-analysis with surface under the cumulative ranking curve (SUCRA) was used to estimate the comparative efficacy of drug classes and individual SSRIs.
Results 87 studies including a total of 12800 participants and 12 drug classes were eligible for inclusion. Almost all the studies (86/87) had some concern or were at high risk of bias. Network meta-analysis of remission with consistent results indicated that tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors, SSRIs, and serotonin-noradrenaline reuptake inhibitors (SNRIs) were associated with significantly higher remission rates than placebo, with risk ratios of 1.39 (95% confidence interval 1.26 to 1.54), 1.47 (1.36 to 1.60), 1.30 (1.00 to 1.69), 1.38 (1.26 to 1.50), and 1.27 (1.12 to 1.45), respectively. SUCRAs identified benzodiazepines (84.5%, mean rank=2.4), tricyclic antidepressants (68.7%, 3.8), and SSRIs (66.4%, 4.0) as the top three best treatments for remission. However, tricyclic antidepressants, benzodiazepines, and SSRIs were also significantly associated with increased risk of adverse events compared with placebo, with risk ratios of 1.79 (1.47 to 2.19), 1.76 (1.50 to 2.06), and 1.19 (1.01 to 1.41), respectively. Consistency assumption of adverse events was upheld but could still be present on removal of studies with high percentages of women participants and those with agoraphobia. A SUCRA cluster ranking plot considering both remission and adverse events among all drug classes indicated that SSRIs were associated with high remission and low risk of adverse events. Among individual SSRIs, sertraline and escitalopram provided high remission with an acceptable risk of adverse events.
Conclusion The findings suggest that SSRIs provide high rates of remission with low risk of adverse events for the treatment of panic disorder. Among SSRIs, sertraline and escitalopram were associated with high remission and low risk of adverse events. The findings were, however, based on studies of moderate to very low certainty levels of evidence, mostly as a result of within study bias, inconsistency, and imprecision of the findings reported.
DOI: 10.1136/bmj-2021-066084
Source: https://www.bmj.com/content/376/bmj-2021-066084
BMJ-British Medical Journal:《英国医学杂志》，创刊于1840年。隶属于BMJ出版集团，最新IF：93.333
官方网址：http://www.bmj.com/
投稿链接：https://mc.manuscriptcentral.com/bmj
本期文章：《英国医学杂志》：Online/在线发表
