Portal de Periódicos da CAPES

Cyclosporine Use in Epidermal Necrolysis Is Associated with an Important Mortality Reduction: Evidence from Three Different Approaches

2017; Elsevier BV; Volume: 137; Issue: 10 Linguagem: Inglês

10.1016/j.jid.2017.05.022

1523-1747

Carlos González‐Herrada, Sara Rodríguez‐Martín, Lucía Cachafeiro, Victoria Lerma, Olga González, José A. Lorente, Antonio Rodríguez, J. González-Ramos, Gastón Roustán, Elena Ramı́rez, Teresa Bellón, Francisco J. de Abajo, Teresa Bellón, Rosario Cabañas, Lucía Cachafeiro, A. García de Lorenzo, J. González-Ramos, Olga Hernández, Pedro Herranz, Elena Ramı́rez, Elena Bravo, Yolanda Alonso, José Antonio Aramburu, Natalia Cámara, Olga González, Carlos González‐Herrada, Olga Laosa, José A. Lorente, Amelia Moscoso, Concepción Payares, Gastón Roustán, Francisco J. de Abajo, A. González Quesada, Victoria Lerma, Sara Rodríguez‐Martín,

Contact Dermatitis and Allergies

Several immunomodulatory agents are used in the treatment of epidermal necrolysis, but evidence of their efficacy is limited. The Autonomous Community of Madrid has two reference burn units to which all patients with epidermal necrolysis are referred. One burn unit has mostly used cyclosporine (CsA), and the other has used non-CsA therapies (mainly high-dose intravenous immunoglobulin). The allocation of patients to one or the other burn unit was mainly based on proximity, resembling a random assignment. Thus, we took advantage of this “natural experiment” to estimate the mortality risk ratio (MRR) of CsA (n = 26) compared with non-CsA (n = 16) treatment using hospital as an instrumental variable over the period from 2001 to 2015. We also computed the observed versus expected (O/E) MRR in a case series of 49 CsA-treated patients (including 23 patients from other regions treated in Madrid), and using the Score for Toxic Epidermal Necrolysis (i.e., SCORTEN) scale to estimate the expected values. The instrumental variable-based MRR of CsA versus non-CsA was 0.09 (95% confidence interval = 0.00–0.49). The O/E analysis also showed a reduction in mortality risk (MRROE = 0.42; 95% confidence interval = 0.14–0.99). We identified five other case series of CsA-treated patients providing MRROE and meta-analyzed their results. The pooled MRROE (including from this study) was 0.41 (95% confidence interval = 0.21–0.80). All three approaches consistently show that CsA reduces the mortality in epidermal necrolysis patients. Several immunomodulatory agents are used in the treatment of epidermal necrolysis, but evidence of their efficacy is limited. The Autonomous Community of Madrid has two reference burn units to which all patients with epidermal necrolysis are referred. One burn unit has mostly used cyclosporine (CsA), and the other has used non-CsA therapies (mainly high-dose intravenous immunoglobulin). The allocation of patients to one or the other burn unit was mainly based on proximity, resembling a random assignment. Thus, we took advantage of this “natural experiment” to estimate the mortality risk ratio (MRR) of CsA (n = 26) compared with non-CsA (n = 16) treatment using hospital as an instrumental variable over the period from 2001 to 2015. We also computed the observed versus expected (O/E) MRR in a case series of 49 CsA-treated patients (including 23 patients from other regions treated in Madrid), and using the Score for Toxic Epidermal Necrolysis (i.e., SCORTEN) scale to estimate the expected values. The instrumental variable-based MRR of CsA versus non-CsA was 0.09 (95% confidence interval = 0.00–0.49). The O/E analysis also showed a reduction in mortality risk (MRROE = 0.42; 95% confidence interval = 0.14–0.99). We identified five other case series of CsA-treated patients providing MRROE and meta-analyzed their results. The pooled MRROE (including from this study) was 0.41 (95% confidence interval = 0.21–0.80). All three approaches consistently show that CsA reduces the mortality in epidermal necrolysis patients.