Department of Pharmacology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India.
Department of Pharmacology, GMERS Medical College, Gotri, Gujarat, India.
Indian J Dermatol Venereol Leprol. 2021 Sep-Oct;87(5):628-644. doi: 10.25259/IJDVL_605_19.
Limited evidence is available about effectiveness and choice of immunomodulating treatment modalities for toxic epidermal necrolysis (TEN).
To compare the effectiveness of interventions to reduce mortality in patients of toxic epidermal necrolysis through network meta-analysis.
Studies were retrieved using PubMed, Google Scholar and Cochrane Database of Systematic Reviews from inception to September 18, 2018. Only English language articles were considered. Observational and randomized controlled studies having ≥ 5 TEN patients in each intervention arm were included. Two investigators independently extracted study characteristics, intervention details and mortality data. Bayesian network meta-analysis was performed using the Markov chain Monte Carlo (MCMC) approach through the random effect model. The ranking analysis was done to provide a hierarchy of interventions. The consistency between direct and indirect evidence was assessed through node spit analysis. The primary outcome was to compare the mortality [Odds ratio OR (95% credibility interval CrI)] among all treatment modalities of TEN.
Twenty-four studies satisfying the selection criteria were included. The network analysis showed improved survival with cyclosporine as compared to supportive care [OR- 0.19 (95% CrI: 0.05, 0.59)] and intravenous immunoglobulin [OR- 0.21 (95% CrI: 0.05, 0.76)]. The hierarchy of treatments based on "surface under the cumulative ranking curves" (SUCRA) value were cyclosporine (0.93), steroid+intravenous immunoglobulin (0.76), etanercept (0.59), steroids (0.46), intravenous immunoglobulin (0.40), supportive care (0.34) and thalidomide (0.02). No inconsistencies between direct and indirect estimates were observed for any of the treatment pairs.
Evidence is mainly based on retrospective studies.
The use of cyclosporine can reduce mortality in TEN patients. Other promising immunomodulators could be steroid+intravenous immunoglobulin combination and etanercept.
关于治疗中毒性表皮坏死松解症（TEN）的免疫调节治疗方法的有效性和选择，目前的证据有限。
通过网络荟萃分析比较各种干预措施在降低 TEN 患者死亡率方面的效果。
检索了从创建到 2018 年 9 月 18 日在 PubMed、Google Scholar 和 Cochrane 系统评价数据库中发表的英文文章。仅纳入了干预组中每个干预组中 TEN 患者≥5 例的观察性和随机对照研究。两位研究者独立提取研究特征、干预细节和死亡率数据。使用 Markov 链蒙特卡罗（MCMC）方法通过随机效应模型进行贝叶斯网络荟萃分析。通过节点分裂分析评估直接证据和间接证据的一致性。主要结局是比较 TEN 所有治疗方法的死亡率[比值比（OR）（95%可信区间 CrI）]。
满足选择标准的 24 项研究被纳入分析。网络分析显示，与支持性治疗相比，环孢素治疗可提高生存率[OR-0.19（95%CrI：0.05，0.59）]和静脉注射免疫球蛋白[OR-0.21（95%CrI：0.05，0.76）]。基于“累积排序曲线下面积”（SUCRA）值的治疗层次结构为环孢素（0.93）、皮质类固醇+静脉注射免疫球蛋白（0.76）、依那西普（0.59）、皮质类固醇（0.46）、静脉注射免疫球蛋白（0.40）、支持性治疗（0.34）和沙利度胺（0.02）。任何治疗组之间均未观察到直接和间接估计值之间的不一致。
证据主要基于回顾性研究。
环孢素的使用可以降低 TEN 患者的死亡率。其他有前途的免疫调节剂可能是皮质类固醇+静脉注射免疫球蛋白联合治疗和依那西普。
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