Canada’s Drug Agency | Drugs, Health Technologies and Systems.

Tuberculosis Screening for People with Chronic Conditions

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Question(s)

1. What are the evidence-based guidelines regarding tuberculosis screening for populations with existing chronic conditions?

Key Message

Five guidelines were identified that provide recommendations about screening for tuberculosis in people with chronic conditions. These guidelines cover populations with HIV, psoriasis vulgaris, solid organ and stem transplants, chronic inflammation, and compromised immune systems. Three guidelines recommend regularly screening for latent and active tuberculosis in people diagnosed with HIV or those taking medication that suppresses their immune system. One guideline for patients with psoriasis recommends using interferon-gamma release assay and a chest X-ray to rule out tuberculosis infection before immunosuppressant treatment is initiated and during treatment. Two guidelines recommend using both the interferon-gamma release assay and the tuberculin skin test at the same time to screen for latent tuberculosis infection in people with HIV, people with or who need an organ or stem cell transplant, and in people taking medication that suppresses their immune system. One guideline for people living with HIV recommends using a rapid nucleic acid amplification test to confirm clinical suspicions of active tuberculosis in these patients.

Last Updated : May 13, 2021

Abiraterone Acetate for Metastatic Castrate Sensitive Prostate Cancer

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Question(s)

1. What is the clinical effectiveness of abiraterone acetate combined with ADT for mCSPC? 2. What is the cost-effectiveness of abiraterone acetate combined with ADT for mCSPC?

Key Message

The use of abiraterone acetate for the treatment of metastatic castration-sensitive prostate cancer is clinically effective. Compared with standard of care, abiraterone acetate was associated with increased overall survival, increased prostate cancerspecific survival, increased progression-free survival, and improved quality of life. Patients treated with abiraterone acetate were at higher risk for grade III to grade V adverse events (severe, life-threatening, or fatal) and were more likely to discontinue treatment compared with standard of care. The incremental cost-effectiveness ratios for both brand and generic abiraterone acetate were estimated to be higher than common willingness-to-pay thresholds.

Last Updated : June 2, 2021

Onabotulinum Toxin A (Botox) for Spasticity in Patients With Acquired Brain Injury

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Question(s)

  1. What is the clinical effectiveness of onabotulinum toxin A (Botox) for reducing spasticity in patients with acquired brain injury?
  2. What is the cost-effectiveness of onabotulinum toxin A (Botox) for reducing spasticity in patients with acquired brain injury?
  3. What are the evidence-based guidelines regarding the use of onabotulinum toxin A (Botox) for reducing spasticity in patients with acquired brain injury?

Key Message

No relevant literature was identified regarding the clinical effectiveness or cost-effectiveness of onabotulinum toxin A (Botox) for reducing spasticity in patients with traumatic or non-traumaticacquired brain injury. Authors of 1 evidence-based guideline recommend the use of botulinum toxin (subtype and formulation not specified) for the treatment of spasticity associated with traumatic brain injury.

Last Updated : April 26, 2021

Bupropion for Major Depressive Disorder or Persistent Depressive Disorder (Dysthymia)

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Question(s)

  1. What is the clinical effectiveness of bupropion for the treatment of adults with major depressive disorder or persistent depressive disorder (dysthymia)?
  2. What is the costeffectiveness of bupropion for the treatment of adults with major depressive disorder or persistent depressive disorder (dysthymia)?

Key Message

Direct and indirect evidence from 6 systematic reviews did not demonstrate a difference in treatment response or remission rates, or functional outcomes, with bupropion as compared to other antidepressants in adults with major depressive disorder.Direct and indirect evidence from 5 systematic reviews did not demonstrate a difference in overall adverse events, overall withdrawals, or withdrawals due to adverse events apart from a possible decreased risk of withdrawal due to adverse events with vortioxetine in a single indirect comparison.Direct and indirect evidence from 2 systematic reviews supports that the risk of sexual dysfunction may be lower with bupropion than other antidepressants (escitalopram, paroxetine, sertraline, and fluoxetine), while 1 systematic review showed no significant difference in sexual function scores between bupropion and venlafaxine.There is limited evidence supporting the cost-effectiveness of bupropion to augment citalopram, and dominance of vortioxetine compared to bupropion, for major depressive disorder with inadequate response to initial therapy.There is a lack evidence surrounding the comparative clinical or cost-effectiveness of bupropion in dysthymia.

Last Updated : April 26, 2021

Non-Pharmacological Interventions for the Management of Concussion

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Canada's Drug Agency initiated scoping for a potential review of the evidence on non-pharmacological interventions for the management of concussion. As part of the scoping exercise, Canada's Drug Agency consulted with jurisdictions across Canada and experts and stakeholders involved in the field of concussion. Although the topic was of interest to the jurisdictions, a full review was not conducted due to competing priorities. The scoping identified a number of issues and questions about the treatment, management, identification, and assessment of concussion.

Last Updated : April 21, 2021

Pharmacological Interventions for Vaping Cessation

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Question(s)

  1. What are the evidence-based guidelines regarding the use of pharmacological vaping cessation interventions in people of any age who use vaping products?

Key Message

The use of electronic nicotine delivery systems and other vaping products is on the rise, and the health effects from these products remain uncertain. No evidence-based guidelines regarding the use of pharmacological vaping cessation interventions were identified. Some guidelines suggest that it may be reasonable to apply smoking cessation interventions and/or protocols for vaping cessation, but no guidance specific to the use of pharmacotherapy was identified.

Last Updated : April 13, 2021

Urethral Inserts for the Management of Adult Male Urinary Incontinence

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Question(s)

  1. What is the clinical effectiveness of male urethral inserts for the management of male urinary incontinence?
  2. What is the cost-effectiveness of male urethral inserts for the management of male urinary incontinence?

Key Message

No evidence was identified regarding the clinical effectiveness of male urethral inserts for the management of male urinary incontinence. No evidence was identified regarding the cost-effectiveness of male urethral inserts for the management of male urinary incontinence.

Last Updated : April 16, 2021

Flash Glucose Monitoring Systems in Pediatric Populations with Diabetes

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Question(s)

  1. What is the comparative clinical effectiveness of monitoring glycemia with flash glucose monitoring systems, versus self-monitoring with blood strips and lancets, in the pediatric population with diabetes requiring insulin therapy?
  2. What is the comparative clinical effectiveness of activating the (hypoglycemia, hyperglycemia, and signal loss) alarms of flash glucose monitoring systems, versus not having or not activating this option, in people with diabetes requiring insulin therapy?

Key Message

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.

Last Updated : April 6, 2021

Rituximab for the Treatment of Myasthenia Gravis: A 2021 Update

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Question(s)

  1. What is the clinical effectiveness of rituximab induction therapy for the treatment of myasthenia gravis for those who are refractory to standard therapy?
  2. What is the clinical effectiveness of rituximab re-treatment for the treatment of myasthenia gravis?
  3. What is the clinical effectiveness of rituximab maintenance therapy for the treatment of myasthenia gravis?
  4. What is the cost-effectiveness of rituximab therapy for the treatment of myasthenia gravis?
  5. What are the evidence-based guidelines regarding the use of rituximab for the treatment of myasthenia gravis?

Key Message

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.

Last Updated : April 19, 2021

Tuberculosis Stigma and Racism, Colonialism, and Migration: A Rapid Qualitative Review

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Question(s)

  1. How does stigma intersect with colonialism, racism, and migration in the context of tuberculosis policy and care?
  2. What opportunities are there to address these intersections in the design, delivery, and offering of care for tuberculosis?

Key Message

Current experiences of tuberculosis policy and care among Indigenous people are interpreted and understood in light of the past colonial violence and cultural genocide. The expressed reluctance to seek health care was often grounded in experiences of colonial violence and racism, pointing toward colonial and racist practice in health care as an important driver of tuberculosis stigma. The ongoing presence of anti-Indigenous racism in Canada’s health care systems underscores the ways that these worries are not confined to historical events but manifest in the interactions across individuals and systems today. For tuberculosis stigma in the context of migration, tuberculosis policies and programs targeting migrant persons or racialized groups were seen as fuelling discriminatory and exclusionary views and practices toward these groups in the wider society and exacerbating tuberculosis stigma. Migrant detention centres were 1 of the sites where tuberculosis stigma was amplified through isolation when diagnosed. Further, the twining of immigration policy with tuberculosis policy led to worries among migrant persons about one’s tuberculosis status and its impact on one’s immigration status, and subsequently a reluctance to access health care. These findings ask us to consider the ways that tuberculosis policy, in concert with immigration policy, can generate tuberculosis stigma. Tuberculosis stigma differs across contexts. It can be both a determinant of, and determined by, other forms of discrimination. Moreover, it requires close attention to the specific setting where tuberculosis stigma is sought to be addressed. The implications of this for tuberculosis policy and care are that a universal, one-size approach to addressing tuberculosis stigma is unlikely to be successful. Rather, program-specific approaches are likely needed that engage with questions as to how different forms of tuberculosis stigma play out in the context of care. Cutting across this review findings were widespread experiences of racism in health care. These findings suggest that, in as much as tuberculosis stigma is a barrier to the uptake of tuberculosis screening and treatment, racism against Indigenous people and racialized migrants remains endemic in Canada’s health care system and may in some cases overshadow the role or experience of tuberculosis stigma. In light of these findings, and again, depending on the particular setting, engaging with anti-racist efforts and challenging white supremacy remain necessary and urgent.

Last Updated : April 19, 2021