Low-quality evidence suggests that treatment with rituximab may be associated with improvements in clinical status, use of concurrent immunomodulatory therapies, quality of life, and various laboratory parameters in patients with myasthenia gravis, compared to before treatment. However, substantial methodological limitations of the included literature limit the use of these findings for informing clinical and policy decisions. Adverse events associated with the use of rituximab were relatively common, occurring in approximately 25% to 45% of patients treated with rituximab. The adverse events experienced by patients were not considered serious by primary study authors. No studies were identified that compared the effectiveness of rituximab to other therapies for the treatment of myasthenia gravis. Summarized studies lacked control groups, meaning that any outcomes observed in study participants should not be attributed to rituximab alone. There is a lack of evidence on the cost-effectiveness of rituximab for the treatment of myasthenia gravis. Additionally, no evidence-based guidelines were identified.
Flash glucose monitoring (FGM) is a method of glucose testing where a sensor inserted into the skin continuously measures interstitial glucose levels. It can be used by people with diabetes to inform treatment decisions, such as insulin dosing, as an alternative or complement to blood glucose testing. Evidence of variable quality from 2 randomized controlled trials and 8 non-randomized studies, including those summarized within systematic reviews, suggests that FGM may improve quality of life, patient satisfaction, diabetes distress, self-efficacy, and frequency of glucose monitoring compared to self-monitoring blood glucose techniques in pediatric populations with type 1 diabetes. Findings related to other outcomes, such as hemoglobin A1C, glucose time in range metrics, and adverse events were mixed or inconclusive (i.e., in some studies the use of FGM was associated with improved outcomes, while in other studies it was not). While the results summarized in this report generally suggest that the use of FGM is associated with improved clinical outcomes in pediatric populations with type 1 diabetes, the limitations of the included literature should be considered when interpreting these findings. No studies were identified that compared the clinical effectiveness of FGM systems with hypoglycemic, hyperglycemia, or signal loss alarms (e.g., FreeStyle Libre 2) to FGM systems without these features (e.g., FreeStyle Libre) in people of any age with diabetes requiring insulin therapy.
“Treat and release” and “treat and refer” protocols or practices refer to the onsite treatment of patients by responding emergency medical services personnel that does not involve transporting patients to health care facilities for additional assessment and treatment. The goal of these protocols is to allow patients to be released from care or to be referred directly to non-emergency services by emergency medical services personnel when appropriate, diverting patients from emergency departments. One health technology assessment that included a relevant randomized controlled trial and economic evaluation and 2 non-randomized studies were identified for inclusion. These studies examined treat and release or treat and refer protocols for treating hypoglycemia and exertional heat stroke, and for attending to older people following a fall. Overall, the clinical evidence summarized in this report suggests that treat and release protocols are as good as, or better than, usual care (i.e., onsite treatment of immediate medical care followed by transportation to health care facilities). Across most reported outcomes, there were no significant differences between patients who received care using treat and release or treat and refer protocols, and those who received usual care; however, there were some instances where the use of these protocols was associated with improvements in some clinical outcomes, such as patient satisfaction, risk for future falls or fractures, and some measures of repeat access to health care services. Findings related to the cost-effectiveness of treat and refer protocols were inconclusive because of the limited generalizability of the findings from the included economic evaluation. The economic evaluation estimated that implementing a treat and refer protocol for older patients who experienced a fall did not result in significant changes to health care resource utilization and did not generate improved health-related quality of life compared to usual care. No evidence-based guidelines regarding the use of treat and release protocols for patients requiring emergency medical services were identified.
Transarterial radioembolization using yttrium-90 (90Y) microspheres is a therapeutic option for patients with intermediate- or advanced-stage hepatocellular carcinoma, including those with recurrent or inoperable hepatocellular carcinoma. Overall, the evidence suggests that patients treated with 90Y-based transarterial radioembolization may experience no difference in overall survival, progression-free survival, and tumour response when compared to patients who received transarterial chemoembolization therapies or systemic treatment with sorafenib or lenvatinib. Patients treated with transarterial radioembolization generally experienced similar rates of adverse events compared to those treated with transarterial chemoembolization, although there were some instances where treatment with transarterial radioembolization led to increased or decreased risks of specific adverse events. The comparative safety of transarterial radioembolization versus systemic treatment with sorafenib was unclear as the included studies did not statistically compare the risks of experiencing adverse events. Evidence regarding the cost-effectiveness of 90Y microspheres for treating hepatocellular carcinoma is conflicting. Three economic evaluations suggest treatment with transarterial radioembolization is likely to be cost-effective or dominant — less costly and more effective — compared to transarterial chemoembolization or systemic therapies, while a single economic study suggested treatment with sorafenib or lenvatinib is most likely to be cost-effective or dominant compared to transarterial radioembolization.
Pharmacogenomic testing is a precision medicine technology that examines genetic variation in medication metabolism. Selected for inclusion in CADTH’s 2023 Watch List, pharmacogenomic testing has the potential to significantly influence the landscape of health care in Canada over the next 5 years. By analyzing an individual’s unique genetic profile, this testing aims to guide personalized treatment strategies that improve therapeutic outcomes, optimize the medication selection process, and enhance patient experiences. The integration of pharmacogenomic testing into clinical practice may pave the way for a more efficient and effective delivery of mental health care. Pharmacogenomic tests for psychiatric disorders that are available in Canada include direct-to-consumer tests — which are paid out of pocket — and tests that are offered as a laboratory service (which may or may not be paid out of pocket). These tests are quite different from each other, including the types and number of genes examined, cost of testing, and methods used for sample collection and analysis. Despite being available for approximately 20 years and that numerous guideline-developing groups and regulators have issued recommendations about the types of pharmacogenomic information that should be used to guide prescribing decisions, pharmacogenomic testing has yet to be integrated into most psychiatric care practices in Canada and worldwide. Although some studies suggest pharmacogenomic testing provides benefits over treatment as usual, the evidence is often conflicting and of limited quality. Concerns related to risk of bias, inconsistency across studies, reproducibility, and generalizability do not allow a clear and consistent interpretation of the results. This Horizon Scan provides an overview of information related to pharmacogenomic testing for psychiatric disorders, a description of some of the published studies, and a summary of some important considerations related to clinician education and training, privacy and confidentiality of health data, health equity, and laboratory capacity should testing become more widely used in Canada.
Codeine and codeine-containing medicines are used to treat people experiencing pain or cough symptoms. Whereas most products containing codeine require a prescription in Canada, some jurisdictions permit over-the-counter sales of products containing low doses of codeine mixed with other non-narcotic medicinal ingredients. Three overviews of reviews and 13 systematic reviews of variable methodological quality failed to identify studies on the effectiveness of low-dose codeine (i.e., 8 mg of codeine per tablet or 20 mg of codeine per 30 mL in liquid products) for the treatment of pain or coughs. There is a lack of evidence on the clinical effectiveness of oral analgesics and oral antitussives containing low doses of codeine.
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