Key Message

What Is the Issue?

Bupropion is a drug used in the treatment of depression. Bupropion is 1 of many treatment options available for depression and is associated with several side effects as well as the potential for misuse. Some patients continue to experience symptoms of depression despite trying multiple medications (known as treatment-resistant depression). Therefore, it is important to determine the place in therapy of bupropion for the treatment of depression.

What Did We Do?

• To help determine the potential place in therapy for bupropion for the treatment of major depressive disorder (MDD) and treatment-resistant depression in adults, we sought to identify and summarize recommendations in evidence-based guidelines.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included publications, and narratively summarized the findings.

What Did We Find?

• We identified 4 evidence-based guidelines that included recommendations on the use of bupropion for MDD. We identified 1 evidence-based guideline that included a recommendation on the use of bupropion for difficult-to-treat depression (defined as persistent depression despite several standard treatments).
• All 4 included guidelines recommend bupropion for the treatment of adults with MDD. Two of the guidelines recommend bupropion as a first-line treatment option. One guideline suggests bupropion as an option for initial pharmacologic treatment or for patients who have previously responded well to pharmacotherapy. One guideline suggests bupropion as an option for adjunctive treatment for patients in the acute phase of moderate to severe MDD who did not respond to treatment with a second-generation antidepressant.
• One guideline suggests bupropion as a second-line adjunctive option for adults with difficult-to-treat depression.

What Does It Mean?

• The included evidence-based guidelines consistently recommend bupropion as an option for the treatment of adults with MDD. Additional factors such as the availability of other options, costs, and patient preferences may also be important to decision-making around the use of bupropion for MDD.
• Only 1 of the included guidelines included a recommendation on the use of bupropion for patients with difficult-to-treat depression. Future evidence-based guidelines that include recommendations on the use of bupropion for treatment-resistant depression would help fill the gaps identified in this report.
   

Key Message

What Is the Issue?

• Gabapentin is 1 of many antiseizure medications available for the treatment of epilepsy in adults; however, there are potential risks associated with its use. Therefore, it is important to determine the place of therapy of gabapentin in the treatment of epilepsy.

What Did We Do?

• To help determine the potential place in therapy for gabapentin in the treatment of epilepsy in adults, we sought to identify and summarize studies of the clinical- and cost-effectiveness of gabapentin as well as recommendations from evidence-based guidelines.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2014. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included publications, and narratively summarized the findings.

What Did We Find?

• We identified 1 systematic review and 1 randomized controlled trial (RCT) that evaluated the efficacy of gabapentin in adults with epilepsy. We identified 5 evidence-based guidelines that included recommendations on the use of gabapentin for epilepsy. We did not identify any studies that evaluated its cost-effectiveness.
• Seizure-free retention at 3 months may be better in adults with epilepsy who were treated with lamotrigine than gabapentin or carbamazepine. There were no differences in other seizure outcomes (such as time to seizure, seizure freedom, or seizure-free retention) for adults with epilepsy treated with gabapentin versus lamotrigine or carbamazepine.
• Adults with epilepsy treated with gabapentin were more likely to experience fair or poor health perception than those treated with oxcarbazepine. There were no differences in other quality of life outcomes (such as anxiety, depression, or worry about seizures) between those treated with gabapentin versus lamotrigine, carbamazepine, oxcarbazepine, or topiramate.
• Withdrawals because of adverse events were similar between adults with epilepsy treated with gabapentin and lamotrigine. There were more systemic toxicities in adults treated with gabapentin than carbamazepine or lamotrigine but there were no differences in neurotoxicities between groups.
• One guideline recommends against the use of gabapentin in people with myoclonic seizures or people with epilepsy with myoclonic-atonic seizures. One guideline states that there is insufficient evidence to consider gabapentin instead of carbamazepine in patients with new-onset focal epilepsy or unclassified generalized tonic-clonic seizures.
• Three guidelines recommend the use of gabapentin in older adults with epilepsy. One guideline recommends the use of gabapentin in people with intellectual disability and epilepsy, if the benefits outweigh the risks or as a second-line option.

What Does It Mean?

• There were few differences in outcomes between adults with epilepsy treated with gabapentin versus other active comparators in the studies we identified. The included guidelines recommended for or against the use of gabapentin depending on patient factors such as age and type of epilepsy or seizures.
• Decision-makers may wish to consider individual patient factors such as age and type of epilepsy or seizures as well as the availability of other treatment options when making decisions on the use of gabapentin for the treatment of epilepsy.
   

Key Message

What Is the Issue?

• Airway management is key to prehospital emergency care, impacting a patient’s survival and recovery. Endotracheal intubation has been considered the gold standard for airway management, yet its success in uncontrolled settings such as outside of the hospital can vary owing to the complexity of the procedure.
• Extraglottic airway devices, which include supraglottic and retroglottic airway devices, are an easier-to-insert alternative to endotracheal intubation; however, their impact on patient outcomes needs review.

What Did We Do?

• We compared the effectiveness of different types of extraglottic airway devices with endotracheal intubation, to inform decisions regarding the use of extraglottic airway devices in out-of-hospital emergencies. We focused on 2 types of supraglottic airway devices (i-gels and laryngeal mask airways) and 1 type of retroglottic airway device (King laryngeal tubes). We also sought to identify evidence-based guidelines regarding the use of extraglottic airway devices for this patient population.
• We searched key resources, including journal citation databases and conducted a focused internet search for relevant evidence published since 2019. Identified literature was reviewed, appraised, and summarized.

What Did We Find?

• Most identified studies were largely comprised of adults who had an out-of-hospital cardiac arrest (OHCA).
• I-gels were associated with higher rates of successful device insertion compared with King laryngeal tubes and laryngeal mask airways. I-gels also had higher rates of survival and return of spontaneous circulation (ROSC), and similar rates of adverse events compared with King laryngeal tubes. Significant differences for first-pass success, survival, and ROSC between i-gels and laryngeal mask airways were not reported. We did not identify any studies that met the inclusion criteria for this review that compared laryngeal mask airways with King laryngeal tubes.
• When compared with endotracheal intubation, i-gels and King laryngeal tubes were associated with higher rates of successful device insertion; however, King laryngeal tubes, laryngeal mask airways, and i-gels tended to have similar clinical outcomes or inconsistent findings. Exceptions included King laryngeal tubes having higher rates of ROSC, and laryngeal mask airways having lower survival to admission, though the difference on survival to discharge was not significant. A subgroup analysis by a randomized controlled trial (RCT) suggested i-gels may lead to better outcomes than endotracheal intubation for specific patients.
• In a nonrandomized study (NRS) that included patients with noncardiac arrest emergencies as well as pediatric patients, extraglottic airway devices were associated with higher rates of first-pass success than endotracheal intubation, with a larger effect seen in pediatric patients.
• One evidence-based guideline suggested supraglottic airway devices may be used for patients who had an OHCA. For pediatric patients who had an OHCA, experienced trauma, or experienced a medical emergency, the guideline recommended supraglottic airway devices compared with endotracheal intubation. The guideline noted missing sufficient evidence to make strong recommendations, yet reported that:
  • supraglottic airway devices were favoured compared with endotracheal intubation for pediatric patients owing to factors such as higher first-pass success rates, harms associated with failed endotracheal intubation attempts, and procedure rarity.
  • for adults who had an OHCA or medical emergency and determining between supraglottic airway devices and endotracheal intubation, the authors recommended considering documented success with endotracheal intubation. The authors recommended supraglottic airway devices for systems without documented success, and for systems with documented success, they suggested using either strategy.

What Does it Mean?

• Additional high-quality randomized studies are needed to fully understand the impact of extraglottic airway devices on patient-important outcomes for OHCA as well as other indications and for pediatric patients.
• Studies reported that i-gels were easier to insert and may also be associated with improved outcomes compared with King laryngeal tubes and similar outcomes compared with laryngeal mask airways. The use of the extraglottic airway devices was reported to result in similar patient outcomes as endotracheal intubation for patients who had out-of-hospital emergencies. Both i-gels and King laryngeal tubes were reported as easier to insert than endotracheal intubation.
• As most identified studies focused on adults who had an OHCA, it is unclear if these findings are generalizable to other patient groups, including patients with other indications and pediatric patients. Few studies reported on adverse events, which may result in an overestimation of the benefits of extraglottic airway devices. The identified evidence-based guideline includes different recommendations for pediatric and adult patients, which indicates that other factors may influence which advanced airway management strategy is optimal.
• Decisions regarding the use of extraglottic airway devices may depend on specific patient factors (e.g., adult versus pediatric, cause of emergency), local factors (e.g., if paramedics can maintain proficiency in endotracheal intubation), and each management strategy’s training needs.