Network meta‐analysis for clinical practice guidelines: a case study on first-line medical therapies for primary open-angle glaucoma

摘要

Network meta-analysis compares multiple treatment options for the same condition and may be useful for developing clinical practice guidelines. To compare treatment recommendations for first‐line medical therapy for primary open angle-glaucoma (POAG) from major updates of American Academy of Ophthalmology’s (AAO) guidelines with the evidence available at the time, using network meta‐analysis. We searched MEDLINE, EMBASE, and The Cochrane Library on March 11, 2014 for randomized controlled trials (RCTs) of glaucoma monotherapies compared with placebo/vehicle/no treatment or other monotherapies. We searched the AAO website in August 2014 to identify AAO POAG guidelines. Eligible RCTs were selected by two independent reviewers and guidelines were selected by one person. One person abstracted recommendations from guidelines and a second person verified. Two people independently abstracted data from included RCTs. We grouped guidelines together based on literature search dates, and analyzed RCTs that existed at 1991, 1995, 1999, 2004, and 2009. The outcome of interest is intraocular pressure (IOP) at 3 months. Only the latest guideline made a specific recommendation‐‐prostaglandins. Network meta‐analyses showed that all treatments were superior to placebo in lowering IOP at 3 months. The mean reduction (95% credible interval) for the highest ranking class compared with placebo were as follows: 1991: beta blockers, 4.01 (0.48‐7.43); 1995: alpha‐2 adrenergic agonists, 5.64 (1.739.50); 1999: prostaglandins, 5.43 (3.387.38); 2004: prostaglandins, 4.75 (3.11‐6.44); 2009: prostaglandins, 4.58 (2.94‐6.24). When comparisons are informed by a small number of studies, the treatment effects and rankings may not be stable. For timely recommendations when multiple treatment options are available, guidelines developers should consider network meta‐analysis.