FEB 08, 2024
Why should I use norepinephrine as my first-line vasopressor in shock?
Comparison of Dopamine and Norepinephrine in the Treatment of Shock (SOAP II)
De Backer D et al. NEJM (March 2010)
Bottom line: This is a multicenter, randomized trial that compared the use of dopamine and norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure in patients with shock. The study included 1679 patients with similar baseline characteristics, 858 of whom were assigned to dopamine and 821 to norepinephrine. The type of shock that was seen most frequently was septic shock (1044 patients [62.2%]), followed by cardiogenic shock (280 patients [16.7%]) and hypovolemic shock (263 patients [15.7%]). The primary outcome was the rate of death at 28 days after randomization, with secondary end points including number of days without need for organ support and occurrence of adverse events. There was no significant difference in death rate between the two groups (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10). However, the use of dopamine was associated with a higher number of adverse events, and particularly arrhythmic events (207 events [24.1%] vs. 102 events [12.4%], P<0.001). Subgroup analysis showed that dopamine was associated with an increased death rate in patients with cardiogenic shock, but not in those with septic or hypovolemic shock. This study suggests that while there is no significant difference in death rate, the use of dopamine may lead to more adverse events compared to norepinephrine.
LINK TO ARTICLE (De Backer et al.)
What’s the evidence behind step-down from IV to PO antibiotics in osteomyelitis?
Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA)
Li H et al. NEJM (January 2019)
Bottom Line: This randomized controlled trial compared the use of oral antibiotics versus intravenous antibiotics for the first 6 weeks of treatment in adults with complex orthopedic infections. The trial included 1054 participants, 527 in each group, being treated for bone and joint infection at 26 U.K. centres. The primary outcome was definitive treatment failure within 1 year after randomization. Endpoint data were available for 1015 patients, with treatment failure occurring in in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Results showed that oral antibiotics were non-inferior to intravenous antibiotics, with a difference in risk of -1.4 percentage points (90% confidence interval [CI], −4.9 to 2.2; 95% CI, −5.6 to 2.9). Safety outcomes were also similar between the two groups. The conclusion was that oral antibiotics can be used as an effective alternative to intravenous antibiotics for the first 6 weeks of treatment for complex orthopedic infections.
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What was the first large RCT comparing DOACs versus LMWH in cancer-associated VTE?
Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism (Hokusai-VTE)
Raskob G et al. NEJM (February 2018)
Bottom Line: This open-label, noninferiority trial compared the use of oral edoxaban and subcutaneous dalteparin in 1050 patients with cancer and acute venous thromboembolism. The primary outcome was a composite of recurrent venous thromboembolism or major bleeding during a 12-month period. Patients received low-molecular weight heparin for at least 5 days and were then randomized to receive either 60 mg of oral edoxaban once daily (edoxaban group) or 200 IU/kg of subcutaneous dalteparin once daily for 1 month followed by 150 IU/kg once daily (dalteparin group). Treatment was given for at least 6 months and up to 12 months. 1046 patients were included in the intention-to-treat analysis. The results showed that edoxaban was noninferior to dalteparin, with a primary-outcome event occurring in 67 of the 522 patients (12.8%) in the edoxaban group as compared with 71 of the 524 patients (13.5%) in the dalteparin group (hazard ratio, 0.97; 95% confidence interval [CI], 0.70 to 1.36; P=0.006 for noninferiority; P=0.87 for superiority). In the edoxaban group, the rate of recurrent venous thromboembolism was lower as compared to the dalteparin group (7.9% vs. 11.3%, −3.4 percentage points; 95% CI, −7.0 to 0.2). However, edoxaban had a higher rate of major bleeding (6.9% vs. 4.0%, difference in risk, 2.9 percentage points; 95% CI, 0.1 to 5.6). Thus, oral edoxaban was noninferior to subcutaneous dalteparin with regard to the composite outcome of recurrent thromboembolism or major bleeding.
LINK TO ARTICLE (Raskob et al.)
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