Your SlideShare is downloading. ×
0
Tocolytic Therapy
for preterm labor
Atosiban vs Nifedipine: meta-
analysis
The perfect tocolytic
 is uniformly effective with complete
fetomaternal safety does not exist
Types
 beta-agonists,
 Ca(2+) channel blockers
 oxytocin receptor antagonists.
 differ in cost, utero-specificity, saf...
Tocolytic agents
 ß-agonist
 ß2-receptor: uterus, blood vessels,
bronchioles
 Stimulate receptoren -> adenyl
cyclase ->...
Side Effects : Maternal
Side Effects: Fetal
RCOG, 2002
 If tocolysis is indicated, B2-agonist
should not be used
 Choice should be either CCB or
Atosiban
CCB: Nifdipine (Adalat )
 Effective
 SE: Hypotension & tachycardia
especially multiple pregnancy
Tractocile® : uterospecific
 Introduced in
Europe in 2000
 Atosiban =
structure similar to
oxytocine -> inhibit
uterus c...
Tractocile®
Tractocile vs Nifedipine
 Both drugs are effective but maternal
adverse events are more with
Nifedipine (Al-Omari et al, ...
In another RCT
 Atosiban was effective in 75% of the cases,
and nifedipin in 65% of the cases, for
delaying delivery for ...
How to use
 Injection
 Not longer than 48 hour infusion
 Total dose: < 330 mg atosiban
Interesting
 Both B2 agonists and Atosiban are
registered in Europe for management
of preterm labor
 Nifedipine: no
Objective of Meta-analysis
 to determine the comparative clinical
value of atosiban versus nifedipine in
women in preterm...
Methodology: Meta-analysis
 Randomised controlled trials
 according to the guidelines of the
Cochrane handbook for syste...
Outcomes
 Prolongation of pregnancy
 prevention of preterm labor
 maternal and fetal side effects and
infant morbidity ...
safety in favor of atosiban:
 there were lower incidence of adverse
drug reactions, flushing, GIT upset,
hypotension, pal...
So
 The balance of evidence indicates
that atosiban is as effective as
nifedipine and is significantly safer
than it
However
We have two major problems:
 Cost
 Real value
Cost
 Atosiban is extremely expensive
compared to Nifidipine
 This is a major limiting issue in the
use of Atosiban
Sustained Tocolysis? Nifidipine
could be better choice
 406 women with threatened preterm
birth randomised to an addition...
Moreover
 Among participants still using
Nifedipine at the time of delivery,
mean blood loss was higher in those
women as...
Why tocolysis?
 To allow for a course of corticosteroids
 To allow for in utero transfer (women
go to tertiary center)
Questioning Tocolysis!!!!
 Patient oriented outcome: neonatal
mortality ????
What a surprise!!!
 No clear evidence was found for the
relative effectiveness of any tocolytic
versus placebo being bene...
Fig Compared to Placebo
Haas D M et al. BMJ 2012;345:bmj.e6226
©2012 by British Medical Journal Publishing Group
No evidence !!
 No evidence of beneficial effect does
not mean Evidence of no value
 No evidence could be due to small
n...
What to do now??
 we have become accustomed to the
fact that tocolytics buy us time.
 The question is : Does it Worth?
To get an answer
 is a large scale multi-centred
randomised non-blinded trial,
analysed by intention to treat.
Till then
 Tocolysis will continue
 So use the most cost effective
modality : CCB
Thank You
Is tocolytic therapy of value ???  Tractocile  vs Nifedipine
Is tocolytic therapy of value ???  Tractocile  vs Nifedipine
Is tocolytic therapy of value ???  Tractocile  vs Nifedipine
Is tocolytic therapy of value ???  Tractocile  vs Nifedipine
Upcoming SlideShare
Loading in...5
×

Is tocolytic therapy of value ??? Tractocile vs Nifedipine

1,791

Published on

tocolytic therapy has been adopted for prevention of preterm labor. is this true: which tocolytic should we use?

Published in: Health & Medicine, Technology
0 Comments
13 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,791
On Slideshare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
112
Comments
0
Likes
13
Embeds 0
No embeds

No notes for slide
  • Fig 7 Rankings for efficacy of tocolytics and adverse events. Graph displays distribution of probabilities for each outcome. Ranking indicates probability that drug class is first “best,” second “best,” etc. Dot-dashed line represents 48 hour delay in delivery. Solid line indicates neonatal mortality. Dashed line indicates respiratory distress syndrome. Dotted line represents all cause maternal side effects
  • Transcript of "Is tocolytic therapy of value ??? Tractocile vs Nifedipine"

    1. 1. Tocolytic Therapy for preterm labor Atosiban vs Nifedipine: meta- analysis
    2. 2. The perfect tocolytic  is uniformly effective with complete fetomaternal safety does not exist
    3. 3. Types  beta-agonists,  Ca(2+) channel blockers  oxytocin receptor antagonists.  differ in cost, utero-specificity, safety, efficacy
    4. 4. Tocolytic agents  ß-agonist  ß2-receptor: uterus, blood vessels, bronchioles  Stimulate receptoren -> adenyl cyclase -> ↑ cAMP -> ↓ calcium  Most important: ritodrine
    5. 5. Side Effects : Maternal
    6. 6. Side Effects: Fetal
    7. 7. RCOG, 2002  If tocolysis is indicated, B2-agonist should not be used  Choice should be either CCB or Atosiban
    8. 8. CCB: Nifdipine (Adalat )  Effective  SE: Hypotension & tachycardia especially multiple pregnancy
    9. 9. Tractocile® : uterospecific  Introduced in Europe in 2000  Atosiban = structure similar to oxytocine -> inhibit uterus contractions
    10. 10. Tractocile®
    11. 11. Tractocile vs Nifedipine  Both drugs are effective but maternal adverse events are more with Nifedipine (Al-Omari et al, 2006)
    12. 12. In another RCT  Atosiban was effective in 75% of the cases, and nifedipin in 65% of the cases, for delaying delivery for more than 7 days.  The maternal side effects in the atosiban group were 17.5%, and in the nifedipin group they were 40%, which had a statistically significant difference (p=0.027). (Kanashian et al, 2005)
    13. 13. How to use
    14. 14.  Injection  Not longer than 48 hour infusion  Total dose: < 330 mg atosiban
    15. 15. Interesting  Both B2 agonists and Atosiban are registered in Europe for management of preterm labor  Nifedipine: no
    16. 16. Objective of Meta-analysis  to determine the comparative clinical value of atosiban versus nifedipine in women in preterm labor by evaluating both, their comparative effectiveness and safety profiles
    17. 17. Methodology: Meta-analysis  Randomised controlled trials  according to the guidelines of the Cochrane handbook for systematic reviews of interventions (version 5.0.1)
    18. 18. Outcomes  Prolongation of pregnancy  prevention of preterm labor  maternal and fetal side effects and infant morbidity and mortality
    19. 19. safety in favor of atosiban:  there were lower incidence of adverse drug reactions, flushing, GIT upset, hypotension, palpitation, and tachycardia in women prescribed atosiban, with the exception of nausea, which was more frequent in such women
    20. 20. So  The balance of evidence indicates that atosiban is as effective as nifedipine and is significantly safer than it
    21. 21. However We have two major problems:  Cost  Real value
    22. 22. Cost  Atosiban is extremely expensive compared to Nifidipine  This is a major limiting issue in the use of Atosiban
    23. 23. Sustained Tocolysis? Nifidipine could be better choice  406 women with threatened preterm birth randomised to an additional 12 days of nifedipine or placebo after completion of a 48-hour initial course of tocolysis.  The probability of adverse perinatal outcomes was similar between groups, as were mean gestational age and birth weight and likelihood of neonatal intensive care unit admission .
    24. 24. Moreover  Among participants still using Nifedipine at the time of delivery, mean blood loss was higher in those women assigned to nifedipine (432 mL vs. 307 mL; P=0.045). Journal Watch Women's Health January 17, 2013
    25. 25. Why tocolysis?  To allow for a course of corticosteroids  To allow for in utero transfer (women go to tertiary center)
    26. 26. Questioning Tocolysis!!!!  Patient oriented outcome: neonatal mortality ????
    27. 27. What a surprise!!!  No clear evidence was found for the relative effectiveness of any tocolytic versus placebo being beneficial for neonatal mortality
    28. 28. Fig Compared to Placebo Haas D M et al. BMJ 2012;345:bmj.e6226 ©2012 by British Medical Journal Publishing Group
    29. 29. No evidence !!  No evidence of beneficial effect does not mean Evidence of no value  No evidence could be due to small number of patients (type II error), or heteregeneity of studies, or different entry point at time of study
    30. 30. What to do now??  we have become accustomed to the fact that tocolytics buy us time.  The question is : Does it Worth?
    31. 31. To get an answer  is a large scale multi-centred randomised non-blinded trial, analysed by intention to treat.
    32. 32. Till then  Tocolysis will continue  So use the most cost effective modality : CCB
    33. 33. Thank You
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×