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PRISMA flow diagram depicting study selection
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Figure 1

PRISMA flow diagram depicting study selection

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 High dose versus no or moderate dose corticosteroids, outcome: 1.2 Serious drug related adverse effects.
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Figure 4

Forest plot of comparison: 1 High dose versus no or moderate dose corticosteroids, outcome: 1.2 Serious drug related adverse effects.

Comparison 1 High dose versus no or moderate dose corticosteroids, Outcome 1 Overall ambulation (short term).
Figuras y tablas -
Analysis 1.1

Comparison 1 High dose versus no or moderate dose corticosteroids, Outcome 1 Overall ambulation (short term).

Comparison 1 High dose versus no or moderate dose corticosteroids, Outcome 2 Serious drug related adverse effects.
Figuras y tablas -
Analysis 1.2

Comparison 1 High dose versus no or moderate dose corticosteroids, Outcome 2 Serious drug related adverse effects.

Summary of findings for the main comparison. Single‐fraction radiotherapy (8 Gy) compared to short‐course radiotherapy (16 Gy in two fractions) for adults with metastatic extradural spinal cord compression

Single‐fraction radiotherapy (8 Gy) compared to short‐course radiotherapy (8 Gy ‐ two fractions over one week) for adults with metastatic extradural spinal cord compression

Patient or population: adults with metastatic extradural spinal cord compression (poor prognosis with visceral metastasis, and no spinal instability or bony impingement of cord)
Intervention: single‐fraction (8 Gy) radiotherapy
Comparison: short‐course (8 Gy ‐ two fractions over one week) radiotherapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Short‐course radiotherapy

Single‐fraction radiotherapy

Ambulation

One month after radiation

693 per 1000

645 per 1000
(569 to 721)

RR 0.93
(0.82 to 1.04)

303
(1 study1)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Single‐fraction and short‐course radiotherapy are probably equally effective in enhancing ambulation (maintaining and regaining ambulation) in the short term.

Survival
Follow‐up: mean 36 months

See comment

See comment

Not estimable

0
(1 study)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Median survival was similar with both radiotherapy schedules (four months).

Reduction in analgesic and narcotic use

One month after radiation

403 per 1000

343 per 1000
(250 to 467)

RR 0.85
(0.62 to 1.16)

271
(1 study)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Single‐fraction and short‐course radiotherapy are probably equally effective in reducing analgesic and narcotic use in the short term.

Urinary continence

One month after radiation

873 per 1000

900 per 1000
(838 to 961)

RR 1.03
(0.96 to 1.1)

303
(1 study)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Single‐fraction and short‐course radiotherapy are probably equally effective in enhancing urinary continence overall, and in the proportions maintaining or regaining continence one month after treatment.

Local recurrence
MRI: follow‐up: median 36 months

27 per 1000

59 per 1000
(18 to 187)

RR 2.21
(0.69 to 7.01)

303
(1 study)

⊕⊕⊝⊝
low2,4

(serious indirectness, serious imprecision)

Short‐course radiotherapy may result in fewer local recurrences than single fraction radiotherapy, but the numbers with local recurrences were too few for the difference to be statistically significant.

Adverse events
Grade 3 oesophagitis, diarrhoea and nausea

20 per 1000

3 per 1000
(0 to 54)

RR 0.14
(0.01 to 2.69)

303
(1 study)

⊕⊕⊕⊝
moderate4

(serious indirectness)

Single‐fraction and short‐course radiotherapy probably do not differ significantly in the incidence of gastrointestinal adverse effects. Serious adverse events or post‐radiotherapy myelopathy were not noted with either treatment schedule.

Quality of life

See comment

See comment

Not estimable

Not assessed.

*The basis for the assumed risk is the risk in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Maranzano 2009 was conducted in multiple sites in Italy and used an equivalence design with the sample size powered to demonstrate equivalence in response rates separately evaluated for ambulatory status (maintaining or regaining ambulation), urinary continence (not requiring a catheter), and reduction in back pain (not requiring a narcotic) one month after treatment. Parenteral dexamethasone (8 mg twice daily) was administered from the first day of clinical‐radiologic diagnosis for 4–5 days.
2 Serious indirectness: the trial included those usually given short‐course radiotherapy (those with poor prognosis, with visceral metastasis, and not suitable for surgery). However the evidence for the equivalence of single dose and short‐course radiotherapy is from only one trial from a high‐income country, where early diagnosis and early institution of radiotherapy (within 24 to 48 hours after diagnosis) was possible; these may not be possible in many resource constrained settings. Downgraded 1 level.
3 No imprecision: the trial was powered to demonstrate equivalence in response rates post‐treatment and the difference in response rates with the two radiotherapy schedules was within the pre‐set precision limits. Not downgraded.
4 Serious imprecision: the trial was not powered to detect equivalence for this outcome; the 95% CI of the effect estimate includes no difference. The number of events were few and the sample size was smaller than the optimal sample size. Downgraded 1 level.

Figuras y tablas -
Summary of findings for the main comparison. Single‐fraction radiotherapy (8 Gy) compared to short‐course radiotherapy (16 Gy in two fractions) for adults with metastatic extradural spinal cord compression
Summary of findings 2. Split‐course radiotherapy (8 fractions, 30 Gy) compared to short‐course radiotherapy (2 fractions, 16 Gy) for adults with metastatic extradural spinal cord compression

Split‐course (8 fractions, 30 Gy) radiotherapy compared to short‐course (2 fractions, 16 Gy) radiotherapy for adults with metastatic extradural spinal cord compression

Patient or population: adults with metastatic extradural spinal cord compression (poor prognosis, no spinal instability or bony impingement of cord)
Intervention: split‐course radiotherapy (8 fractions‐ 5 Gy × 3; 3 Gy × 5 = 30 Gy)
Comparison: short‐course radiotherapy (2 fractions × 8 Gy = 16 Gy)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Short‐course radiotherapy (2 fractions)

Split‐course radiotherapy (8 fractions)

Ambulation
One month after treatment

683 per 1000

697 per 1000
(615 to 786)

RR 1.02
(0.9 to 1.15)

276
(1 study1)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Split‐course and short‐course radiotherapy are probably equally effective in enhancing ambulation (maintaining and regaining ambulation) in the short term.

Survival
Follow‐up: median 33 months

See comment

See comment

Not estimable

0
(1 study)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Median survival was similar with both treatment schedules (four months).

Reduction in analgesic and narcotic use

One month after radiation

382 per 1000

486 per 1000
(367 to 639)

RR 1.27
(0.96 to 1.67)

262
(1 study)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Split‐course and short‐course radiotherapy are probably equally effective in reducing analgesic and narcotic use in the short term.

Urinary continence

One month after radiation

901 per 1000

874 per 1000
(838 to 919)

RR 0.97
(0.93 to 1.02)

275
(1 study)

⊕⊕⊕⊝
moderate2,3

(serious indirectness)

Split‐course and short‐course radiotherapy are probably equally effective in enhancing urinary continence overall, and in the proportions maintaining or regaining continence one month after treatment.

Local recurrence
Follow‐up: median 33 months

35 per 1000

4 per 1000
(0 to 61)

RR 0.1
(0.01 to 1.72)

276
(1 study)

⊕⊕⊝⊝
low2,4

(serious indirectness, serious imprecision)

Split‐course radiotherapy probably results in fewer local recurrences than short‐course radiotherapy, but the numbers with local recurrences were too few to demonstrate statistically significant differences.

Adverse events
Grade 3 oesophagitis, diarrhoea, and nausea

21 per 1000

37 per 1000
(9 to 153)

RR 1.77
(0.43 to 7.25)

276
(1 study)

⊕⊕⊕⊝
moderate4

(serious indirectness)

Split‐course and short‐course radiotherapy probably do not differ significantly in the incidence of gastrointestinal adverse effects. Serious adverse events or post‐radiotherapy myelopathy were not noted with either treatment schedule.

Quality of life

See comment

See comment

Not estimable

Not assessed

*The basis for the assumed risk is the risk in the control group. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Maranzano 2005 was conducted in multiple sites in Italy and used an equivalence design with the sample size powered to demonstrate equivalence in response rates separately evaluated for ambulatory status (maintaining or regaining ambulation), urinary continence (not requiring a catheter), and reduction in back pain (not requiring a narcotic) one month after treatment.. Dexamethasone: 8 mg twice daily was given to both arms and tapered after completion of radiotherapy.
2 Serious indirectness: the trial included those usually given short courses of radiotherapy (patients with poor prognosis; no spinal instability or bony impingement causing cord compression). However this trial is from a high‐income country where early diagnosis and early institution of radiotherapy (within 24 hours after diagnosis) was possible; these may not be possible in many low‐ and middle‐income settings. Downgraded 1 level.
3 No imprecision: the trial was powered to demonstrate equivalence in response rates post‐treatment and the difference in response rates with the two radiotherapy schedules was within the pre‐set precision limits. Not downgraded.
4 Serious imprecision: the trial was not powered to detect equivalence for this outcome.. The number of events were few, and the 95% CI of the risk difference indicated non‐appreciable benefits with both schedules. The sample size was smaller than the optimal sample size. Downgraded 1 level.

Figuras y tablas -
Summary of findings 2. Split‐course radiotherapy (8 fractions, 30 Gy) compared to short‐course radiotherapy (2 fractions, 16 Gy) for adults with metastatic extradural spinal cord compression
Summary of findings 3. Laminectomy plus radiotherapy compared to radiotherapy for adults with metastatic extradural spinal cord compression

Laminectomy plus radiotherapy compared to radiotherapy for adults with metastatic extradural spinal cord compression

Patient or population: adults with metastatic extradural spinal cord compression (single lesion, no prior radiotherapy, fit for surgery)
Intervention: laminectomy plus radiotherapy
Comparison: radiotherapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Radiotherapy

Laminectomy plus radiotherapy

Ambulation

At four months

385 per 1000

373 per 1000
(146 to 954)

RR 0.98
(0.38 to 2.48)

29
(1 study1)

⊕⊝⊝⊝
very low2,3,4

(risk of bias, serious indirectness, very serious imprecision)

Laminectomy followed by radiotherapy may offer no advantage over radiotherapy alone in enhancing ambulation. .

Survival

At four months

462 per 1000

563 per 1000
(272 to 1000)

RR 1.22
(0.59 to 2.53)

29
(1 study)

⊕⊝⊝⊝
very low3,4

(serious indirectness, very serious imprecision)

Laminectomy followed by radiotherapy may offer no advantage over radiotherapy alone in improving survival.

Reduction in analgesic use

500 per 1000

440 per 1000
(210 to 905)

RR 0.88
(0.42 to 1.81)

26
(1 study)

⊕⊝⊝⊝
very low3,4

(serious indirectness, very serious imprecision)

Laminectomy followed by radiotherapy may offer no advantage over radiotherapy alone in reducing analgesic use.

Urinary continence

One month after treatment

538 per 1000

32 more per 1000
(232 fewer to 538 more)

RR 1.06
(0.57 to 2.00)

29
(1 study)

⊕⊝⊝⊝
very low2,3,4

(risk of bias, serious indirectness, very serious imprecision)

Laminectomy followed by radiotherapy may offer no advantage over radiotherapy alone in enhancing urinary continence.

Local recurrence

See comment

See comment

Not estimable

Not assessed

Adverse events

See comment

See comment

Not estimable

29

(1 study)

No adverse events were reported with laminectomy plus RT or with RT, but it is unclear if these were systematically ascertained

Quality of life

See comment

See comment

Not estimable

Not assessed

*The basis for the assumed risk is the risk in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1 Data from Young 1980: radiotherapy was given as 30 Gy in 10 fractions (4 Gy/day first 3 days, then 18 Gy in 7 fractions over 14 days), Both arms were given dexamethasone 12 mg; followed by 4 mg four times daily till radiotherapy completion.

2 Serious risk of bias. There were baseline imbalances in the proportions with myelographic block and this negatively influenced effect estimates for the outcomes of ambulation and urinary continence. Downgraded 1 level.
3 Serious indirectness: the trial included those likely to be offered a surgical intervention in preference to radiotherapy. However, the data for the comparative effects of laminectomy versus radiotherapy come from only one small trial done over 30 years ago. Downgraded 1 level.
4 Very serious imprecision. The 95% CI of the effect estimate indicates appreciable benefits for both interventions. The number of events and participants were too few to provide reliable estimates. Downgraded by 2 levels.

Figuras y tablas -
Summary of findings 3. Laminectomy plus radiotherapy compared to radiotherapy for adults with metastatic extradural spinal cord compression
Summary of findings 4. Decompressive surgery plus radiotherapy compared to radiotherapy for adults with metastatic extradural spinal cord compression

Decompressive surgery plus radiotherapy compared to radiotherapy for adults with metastatic extradural spinal cord compression

Patient or population: adults with metastatic extradural spinal cord compression (fit for surgery, paraplegic less than 48 hours, and without multiple discrete compressions or radiosensitive tumours; with cervical or thoracic lesions, and life expectancy three months or more)
Intervention: decompressive surgery plus radiotherapy
Comparison: radiotherapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Radiotherapy

Decompressive surgery plus radiotherapy

Ambulation

Immediately after completing RT

569 per 1000

842 per 1000
(660 to 1000)

RR 1.48
(1.16 to 1.90)

101
(1 study1)

⊕⊕⊝⊝
low2,3

(serious indirectness, serious imprecision)

Surgery plus RT may be superior to RT in enhancing ambulation (maintaining ambulation: and regaining ambulation) in selected patients with MESCC

Survival (short term)

At 30 days

863 per 1000

940 per 1000
(828 to 1000)

RR 1.09
(0.96 to 1.24)

101
(1 study)

⊕⊕⊝⊝
low2,3

(serious indirectness, serious imprecision)

Surgery plus RT may not significantly enhance proportions surviving compared to RT (though median survival may be longer with surgery plus RT: 126 days versus 100 days).

Reduction in analgesic and narcotic use

See comment

See comment

Not estimable

101

(1 study)

See comment

Surgery plus RT may have beneficial effects compared to RT in reducing analgesic use (median daily morphine equivalent dose: 0·4 mg (0 to 60 mg) versus 4·8 mg (0 to 200 mg; P = 0·002).

Urinary continence

See comment

See comment

Not estimable

101

(1 study)

See comment

Surgery plus RT may have beneficial effects compared to RT in enhancing the maintenance of urinary continence (median duration for maintenance of continence: 156 days versus 17 days; P = 0.016)4.

Local recurrence

See comment

See comment

Not estimable

See comment

Not reported

Adverse events

See comment

See comment

Not estimable

101

(1 study)

See comment

No serious adverse events were seen after surgery or after RT. In 10 participants randomised to RT who subsequently had surgery, 4 (40%) had surgical complications (wound infections‐3; failure of fixation‐1). Other adverse events were not reported.

Quality of life

See comment

See comment

Not estimable

See comment

Not reported

*The basis for the assumed risk is the risk in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1 Data from Patchell 2005: surgery ‐ direct circumferential decompression with or without stabilisation within 24 hours of randomisation; Radiotherapy‐ 3 Gy x 10, starting within 24 hours after randomisation (in most), or within 14 days of surgery. All patients were given 100 mg dexamethasone immediately at diagnosis, then 24 mg every 6 hours until the start of radiotherapy or surgery, after which steroids were then reduced and continued until completion of radiotherapy.
2 Serious indirectness: this trial selected patients who were good candidates for surgery and excluded participants with radiosensitive tumours; 18 patients given RT had unstable spines. These biased the results against radiotherapy and the participants given RT were not representative of the usual candidates for RT. Emergency surgery was offered within 24 hours of the diagnosis of cord compression, within 48 hours of onset of paraplegia and within two weeks of the onset of symptoms in most. RT was also offered as an emergency. These may not be feasible outside a clinical trial setting and in healthcare systems in resource poor countries. Downgraded 1 level.
3 Serious imprecision. This trial was stopped early for apparent benefit after recruiting only 50% of the estimates sample. Truncated RCTs are at risk of over‐estimating benefits (Bassler 2010). The evidence in favour of surgery comes from only one trial with 101 participants, and the sample size is smaller than the optimal information size. Downgraded 1 level.

4 Based on secondary analysis in the Patchell 2005 report using a Cox model with all covariates included

Figuras y tablas -
Summary of findings 4. Decompressive surgery plus radiotherapy compared to radiotherapy for adults with metastatic extradural spinal cord compression
Summary of findings 5. High‐dose corticosteroids compared to moderate‐dose or no corticosteroids for adults with metastatic extradural spinal cord compression

High‐dose corticosteroids compared to moderate‐dose or no corticosteroids for adults with metastatic extradural spinal cord compression

Patient or population: adults with metastatic extradural spinal cord compression (without peptic ulceration or infection; mixed prognosis)
Intervention: high‐dose corticosteroids (96 mg and 100 mg bolus)
Comparison: moderate‐dose (10 mg and 16 mg) or no corticosteroids

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Moderate‐dose or no corticosteroids

High dose corticosteroids

Ambulation

Follow‐up: one week to three months

550 per 1000

594 per 1000
(446 to 798)

RR 1.08
(0.81 to 1.45)

105
(3 studies1)

⊕⊕⊝⊝
low2

(very serious imprecision)

High dose steroids may not offer any beneficial effects compared to moderate dose steroids in enhancing ambulation.

Survival (long term)

Over two years

100 per 1000

111 per 1000
(25 to 505)

RR 1.11
(0.24 to 5.05)

57
(1 study)

⊕⊕⊝⊝
low2

(very serious imprecision)

High dose steroids may offer no beneficial effects compared to no steroids in enhancing long term survival.

Pain reduction

909 per 1000

782 per 1000
(564 to 1000)

RR 0.86
(0.62 to 1.20)

25
(1 study)

⊕⊕⊝⊝
low3

(very serious imprecision)

High dose steroids may offer no beneficial effects compared to moderate dose steroids in reducing pain.

Urinary continence

One week after treatment

533 per 1000

629 per 1000
(352 to 1000)

RR 1.18
(0.66 to 2.13)

34
(1 study)

⊕⊕⊝⊝
low2

(very serious imprecision)

High dose steroids may offer no beneficial effects compared to moderate dose steroids in enhancing urinary continence.

Local recurrence

See comment

See comment

Not estimable

See comment

Not reported

Serious adverse events

See comment

See comment

RR 8.02
(1.03 to 62.37)

77
(2 studies)

⊕⊕⊕⊝
moderate3

(serious imprecision)

Serious adverse events (such as perforated gastric ulcer, psychoses and deaths due to infection) occurred only with high dose steroids: 6/36 (17%) versus 0/41 (0%) on moderate dose (N = 11) or no steroids (N = 30).

Quality of life

See comment

See comment

Not estimable

See comment

Not reported

*The basis for the assumed risk is the median control group risk across studies for pooled data or the control group risk in single studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Vecht 1989 and Graham 2006 compared high dose (100 to 96 mg dexamethazone) versus moderate dose steroids (10 to 16 mg); Sorensen 1994 compared a single IV dose of 100 mg dexamethazone with saline placebo. The three trials were free of the risk of serious biases for efficacy outcomes.
2 Very serious imprecision: the 95% CI of the effect estimates indicate appreciable benefit for high dose and moderate dose or no steroids. Downgraded 2 levels.

3 Serious imprecision: the 95% CI of the effect estimate indicates appreciable and non‐appreciable benefits with moderate dose or no steroids; and the number of events and participants were too few to provide reliable estimates. Downgraded 1 level.

Figuras y tablas -
Summary of findings 5. High‐dose corticosteroids compared to moderate‐dose or no corticosteroids for adults with metastatic extradural spinal cord compression
Comparison 1. High dose versus no or moderate dose corticosteroids

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Overall ambulation (short term) Show forest plot

3

105

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.81, 1.45]

1.1 High dose versus no corticosteroids

1

57

Risk Ratio (M‐H, Fixed, 95% CI)

1.29 [0.93, 1.78]

1.2 High versus moderate corticosteroids

2

48

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.46, 1.43]

2 Serious drug related adverse effects Show forest plot

2

77

Risk Ratio (M‐H, Fixed, 95% CI)

8.02 [1.03, 62.37]

2.1 High dose versus no corticosteroids

1

57

Risk Ratio (M‐H, Fixed, 95% CI)

9.96 [0.56, 176.92]

2.2 High dose versus moderate dose corticosteroids

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

6.0 [0.32, 111.04]

Figuras y tablas -
Comparison 1. High dose versus no or moderate dose corticosteroids