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Cochrane Database of Systematic Reviews

Exámenes genéticos para la prevención de la erupción cutánea grave inducida por fármacos

Información

DOI:
https://doi.org/10.1002/14651858.CD010891.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 17 julio 2019see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Piel

Copyright:
  1. Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Ana Alfirevic

    Correspondencia a: Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK

    [email protected]

  • Munir Pirmohamed

    Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK

  • Branka Marinovic

    Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia

  • Linda Harcourt‐Smith

    c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK

  • Andrea L Jorgensen

    Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, UK

  • Tess E Cooper

    Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia

Contributions of authors

AA was the contact person with the editorial base.
AA co‐ordinated contributions from the co‐authors and wrote the final draft of the review.
AJ and AA screened papers against eligibility criteria.
AJ and AA obtained data on ongoing and unpublished studies.
AJ and AA appraised the quality of papers.
AJ and AA extracted data for the review.
AA sought additional information about papers.
AA entered data into Review Manager 5.
AA, AJ, MP and BM analysed and interpreted data.
AA, AJ, MP and BM worked on the methods sections.
AA and MP drafted the clinical sections of the background and responded to the clinical comments of the referees.
AJ responded to the methodological and statistical comments of the referees.
LHS was the consumer co‐author and checked the review for readability and clarity, as well as ensuring outcomes are relevant to consumers.
AA is the guarantor of the update.

Disclaimer

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Skin Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, or NHS.

Sources of support

Internal sources

  • No financial support, Other.

External sources

  • The National Institute for Health Research (NIHR), UK.

    The NIHR, UK, is the largest single funder of the Cochrane Skin Group.

Declarations of interest

AA: none known.
MP: none known.
BM: none known.
LHS: none known.
ALJ: none known.
TC: none known.

Acknowledgements

The Cochrane Skin editorial base would like to thank the following people who commented on this review: the clinical referee, Neil H Shear; and the consumer referee, Jack Tweed. We would also like to thank Jessica Sharp for copy‐editing the review.

Version history

Published

Title

Stage

Authors

Version

2019 Jul 17

Genetic testing for prevention of severe drug‐induced skin rash

Review

Ana Alfirevic, Munir Pirmohamed, Branka Marinovic, Linda Harcourt‐Smith, Andrea L Jorgensen, Tess E Cooper

https://doi.org/10.1002/14651858.CD010891.pub2

2013 Dec 19

Genetic testing for prevention of severe drug‐induced skin rash

Protocol

Ana Alfirevic, Munir Pirmohamed, Branka Marinovic, Andrea L Jorgensen, Linda Harcourt‐Smith

https://doi.org/10.1002/14651858.CD010891

Differences between protocol and review

Our objectives and eligibility criteria remained the same between the protocol and the review. After the protocol stage, two new outcomes were added to our secondary outcomes: safety of abacavir and cost‐effectiveness. However, these were not in any way conditional to our eligibility criteria, nor were they influenced by the availability of the data from included studies.

We were unable to implement several methodologies from the protocol, due to there only being one included study. The following methods are not applicable with one study: addressing unit of analysis issues; dealing with missing data (contact was made but we did not receive a response); assessment of heterogeneity; assessment of reporting bias; data synthesis; subgroup analysis and investigation of heterogeneity (not applicable with one study, and outcomes not addressed); and sensitivity analysis.

Types of participants: we clarified how we would handle a study with only a subset of relevant participants; however, we did not encounter such studies.

Types of interventions: in the review, we additionally stated that we excluded any participants who had previously been administered the study drugs because of accurate causality assessment. Furthermore, we clarified the comparator in the review and included the following statement "and compared to standard clinical practice which does not include a genetic test".

Types of outcome measures: we added a definition of ‘severe drug‐induced skin rash’ to our primary outcome because phenotype definitions vary widely in the literature and some study authors report hypersensitivity reactions and SJS/TEN as severe or serious drug‐induced skin rash. We also added 'death' as a secondary outcome.

Searching other resources: although not planned in the protocol, we additionally checked the bibliographies of published reviews for relevant references and we requested relevant information from the authors of the included study.

Data extraction and management: we had planned to consult MP if consensus was not reached, but instead discussed disagreements with TC because authorship changed due to availability.

Assessment of risk of bias in included studies: we had planned in the protocol for all authors to assess the risk of bias of three studies as a pilot but did not do this because only one study fulfilled our inclusion criteria.

Unit of analysis issues: we did not encounter cluster‐randomised trials, so did not have to deal with the issues we had planned for in the protocol.

Dealing with missing data: we planned to report the limited results from studies with missing summary data in narrative form in the results section and consider whether they are consistent with the results of the meta‐analysis for that outcome. Also, where appropriate, we had planned to make assumptions about the missing data (e.g. assuming all missing values to have a particular value, e.g. an adverse event) and conduct sensitivity analyses to test how sensitive the analyses are to our assumptions. We had planned to address the potential implications of the missing data in the Discussion section. These plans were not implemented because only one study was included in this review which only reported data on two of our secondary outcomes.

Assessment of heterogeneity, Assessment of reporting biases, Subgroup analysis and investigation of heterogeneity, and Sensitivity analysis: we could not implement our planned methods because only one studies was included in this review.

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Flowchart of interventions (genetic testing) and outcomes (skin rash) in a patient population prescribed drug X
Figuras y tablas -
Figure 1

Flowchart of interventions (genetic testing) and outcomes (skin rash) in a patient population prescribed drug X

Study flow diagram.
Figuras y tablas -
Figure 2

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 3

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.
Figuras y tablas -
Figure 4

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

Forest plot of comparison: 1 Genetic testing vs no testing, outcome: 1.1 Hypersensitivity (HSS).
Figuras y tablas -
Figure 5

Forest plot of comparison: 1 Genetic testing vs no testing, outcome: 1.1 Hypersensitivity (HSS).

Forest plot of comparison: 1 Genetic testing with skin patch testing versus no genetic testing with skin patch testing, outcome: 1.1 Hypersensitivity (HSS) immunologically confirmed.
Figuras y tablas -
Figure 6

Forest plot of comparison: 1 Genetic testing with skin patch testing versus no genetic testing with skin patch testing, outcome: 1.1 Hypersensitivity (HSS) immunologically confirmed.

Drug‐induced skin rash: top panel = maculopapular exanthema, bottom panel = Steven Johnson Syndrome (blistering skin rash with skin detachment)
Figuras y tablas -
Figure 7

Drug‐induced skin rash: top panel = maculopapular exanthema, bottom panel = Steven Johnson Syndrome (blistering skin rash with skin detachment)

Comparison 1 Genetic testing with skin patch testing versus no genetic testing with skin patch testing, Outcome 1 Hypersensitivity (HSS), immunologically confirmed.
Figuras y tablas -
Analysis 1.1

Comparison 1 Genetic testing with skin patch testing versus no genetic testing with skin patch testing, Outcome 1 Hypersensitivity (HSS), immunologically confirmed.

Comparison 2 Genetic testing versus no testing, Outcome 1 Hypersensitivity (HSS).
Figuras y tablas -
Analysis 2.1

Comparison 2 Genetic testing versus no testing, Outcome 1 Hypersensitivity (HSS).

Prospective genetic HLA‐B*57:01 screening compared with standard care for drug‐induced skin rash

Patient or population: patients with HIV‐1 infection and a pre‐established clinical need for treatment with an antiretroviral drug regimen containing abacavir but with an unknown HLA‐B*57:01 status.

Settings: secondary care clinics

Intervention: prospective genetic screening for the HLA‐B*57:01 allele

Comparison: no prospective genotyping, standard‐of‐care treatment

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Standard Carea

Prospective genetic HLA‐B*57:01 screening

Severe skin drug‐induced rash

No data

Not assessed

Long‐term sequelae

No data

Not assessed

Hospitalisation for drug‐induced skin reaction

No data

Not assessed

SJS/TEN (Stevens‐Johnson syndrome/toxic epidermal necrolysis)

See hypersensitivity

Not assessable

AGEP (acute generalised exanthematous pustulosis)

No data

Not assessed

HSS (hypersensitivity) reaction including SJS/TEN (clinically diagnosed) (6 weeks clinical assessment)

78 per 1000

34 per 1000
(22 to 52)

RR 0.43 (0.28 to 0.67)

1650 participants
(1 study)

⊕⊕⊕⊝
moderateb

HSS reaction including SJS/TEN (immunologically confirmed) (6 weeks clinical assessment)

27 per 1000

0 per 1000

RR 0.02 (0.00 to 0.37)

1644 participants (1 study)

⊕⊕⊕⊝

moderateb

Death

No data

Not assessed

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. 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.

a The assumed risk is estimated from the event rate (confirmed clinically diagnosed occurrences of HSS including SJS/TEN or immunologically confirmed) in the control arm of the included study.

b We downgraded the evidence to moderate quality, due to study limitations (high risk of detection and attrition bias).

Figuras y tablas -
Table 1. Glossary of terms

Term

Explanation

Allele

One of two or more alternative forms of a gene at corresponding sites (loci) on homologous chromosomes

Antiretroviral

A class of drugs that inhibit the activity of retroviruses that cause HIV infection

Hardy‐Weinberg equilibrium

This states that allele and genotype frequencies in a population will remain constant from generation to generation in the absence of other evolutionary influences

HLA

Human leukocyte antigen: a group of protein molecules located on bone marrow and other cells that can provoke an immune response

Hypersensitivity

A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign substance, such as a drug

Immunologically confirmed

Patch testing is done to see whether a particular drug is causing allergic skin reaction. Patch test can detect delayed allergic or immunological reaction and confirm the diagnosis of hypersensitivity.

Phenotypes

The set of observable characteristics of an individual resulting from the interaction of its genotype with the environment

Polymorphic

A variation in the DNA that is too common to be due merely to new mutation. A polymorphism must have a frequency of at least 1% in a population

Maculopapular rash

A rash with both macules (flat and coloured like a freckle) and papules (a small raised spot)

Sequelae

A condition that is a consequence of a previous disease or injury

T‐cells

Another term for T‐lymphocyte, a type of cell that participates in immune response

Figuras y tablas -
Table 1. Glossary of terms
Table 2. Associations between drug‐induced skin injury and genetic variants in the HLA genes

Drugs associated with skin injury

Class of drug

HLA allele

Population

Reference

Stevens‐Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)

Allopurinol

Antiuric acid

B*5801

Han Chinese

Hung 2005

Thai

Tassaneeyakul 2009

Japanese

Kaniwa 2008

Malay

Ding 2010

Carbamazepine

Antiepileptic

B*1502

Han Chinese

Cheung 2013; Chung 2004; Chong 2013; Hung 2006; Man 2007

Thai

Kulkantrakorn 2012; Locharernkul 2008; Tassaneeyakul 2010; Tangamornsuksan 2013

Malay

Ding 2010

Indian

Mehta 2009

A*3101

White

Amstutz 2013; McCormack 2011;

A*3101

Japanese

Ozeki 2011

Phenytoin

Antiepileptic

B*1502

Han Chinese

Hung 2010; Man 2007

Thai

Locharernkul 2008;

Oxicam

Non‐steroidal anti‐inflammatory drug (NSAID)

A2, B12

White

Roujeau 1987

Sulphamethoxazole

Antibiotic

A29, B12, DR7

White

Roujeau 1986

Hypersensitivity syndrome (drug‐induced hypersensitivity syndrome (DIHS) or drug reaction with eosinophilia and systemic symptoms (DRESS))

Abacavir

Antiretroviral

B*57:01

White

Hetherington 2002; Hughes 2004a; Mallal 2002; Mallal 2008; Martin 2004

African American

Hughes 2004b; Saag 2008

Aminopenicillins

Antibiotic

A2, Drw52

White

Romano 1998

Nevirapine

Antiretroviral

DRB1*01

White ‐ Australian

Martin 2005

DRB1*01

White ‐ French

Vitezica 2008

Cw8, B14

White ‐ Italian

Littera 2006

Cw8

Japanese

Gatanaga 2007

B*3505

Thai

Chantarangsu 2009

Cw4

Thai

Likanonsakul 2009

C*0404

Black African

Carr 2013

Cw*04

Chinese

Gao 2012

Aspirin

NSAIDs

DRB1*1302, DQB1*0609

Kim 2005; Palikhe 2008

NSAIDs

DR11

Quiralte 1999

Iodine contrast media

DR

White ‐ Spanish

Torres 2008

Paraphenylenediamine

Hair dye

DP

White ‐ German

Sieben 2002

Gold sodium thiomalate

Treatment of rheumatoid arthritis

DR5

White ‐ Spanish

Rodriguez‐Pérez 1994

Lamotrigine

Antiepileptic

B*5801, A*6801

White

Kazeem 2009

Trichloroethylene

Industrial solvent, dry cleaning

B*1301

Japanese

Li 2007; Watanabe 2010

Fixed drug eruptions

Co‐trimoxazole

Antibiotic

A30, B13, Cw6

White ‐ Turkish

Ozkaya‐Bayazit 2001

Feprazone

Analgesic

B22

Pellicano 1997

Figuras y tablas -
Table 2. Associations between drug‐induced skin injury and genetic variants in the HLA genes
Comparison 1. Genetic testing with skin patch testing versus no genetic testing with skin patch testing

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Hypersensitivity (HSS), immunologically confirmed Show forest plot

1

1644

Risk Ratio (M‐H, Fixed, 95% CI)

0.02 [0.00, 0.37]

Figuras y tablas -
Comparison 1. Genetic testing with skin patch testing versus no genetic testing with skin patch testing
Comparison 2. Genetic testing versus no testing

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Hypersensitivity (HSS) Show forest plot

1

1650

Risk Ratio (M‐H, Fixed, 95% CI)

0.43 [0.28, 0.67]

Figuras y tablas -
Comparison 2. Genetic testing versus no testing