PDF《in炉he爉anagement爋f燞eart焖ailure?》

17th Expert Committee on the Selection and Use of Essential Medicines Geneva,

2009 ? Review?of?the?available?evidence?on?Thiazides?Diuretics? in?the?management?of?Heart?Failure? ? FOR?THE?WHO?MODEL?LIST?OF?ESSENTIAL? MEDICINES? ? ? ? CeVEAS?? NHS?Centre?for?the?Evaluation?of?Effectiveness?of?Health?Care? Local?Health?Unit,?Modena?C?Italy? ? WHO?Collaborating?Centre?for?Evidence\Based?Research?Synthesis? and?Guideline?Development?in?Reproductive?Health? ? ? ? ? ? ? ? Person?to?contact:? ? Dr.

?Nicola?Magrini,?MD? CeVEAS? Viale?Muratori?201?41100?Modena.? Tel?+39\059\435200? Fax?+39\059\435222? Web?page?http://www.ceveas.it e\mail:?n.magrini@ausl.mo.it? ? ? ? ? ? ? July?2008? ?

1 Contributors:? ? CeVEAS,?Modena,?Italy? NHS?Centre?for?the?Evaluation?of?the?Effectiveness?of?Health?Care? WHO?Collaborating?Centre?for?Evidence\Based?Research?Synthesis?and?Guideline?Development?in? Reproductive?Health? ? Nicola?Magrini? Director,?Clinical?Pharmacologist? ? Anna?Maria?Marata? Clinical?Pharmacologist,?Cardiologist? ? Simona?Di?Mario? Pediatrician,?Epidemiologist? ? Lisa?Daya? Pharmacologist? ? Luca?Vignatelli? Neurologist,?Epidemiologist? ? ?

2 1.?Summary?statement?of?the?proposal?? Based?on?currently?available?evidence?including?several?guidelines,?direct?evidence?from?a?single? study?(case?series?design),?indirect?evidence?from?one?systematic?review?of?randomized?controlled? trials?and?one?large?randomized?controlled?trial,?it?is?proposed?to?keep?thiazide?diuretics?in?the? WHO? Model? List? of? Essential? Medicines? (EML? 15,? revised? March? 2007)? available? at? the? URL:? http://www.who.int/medicines/publications/08_ENGLISH_indexFINAL_EML15.pdf?(last?accessed? 09?June?2008)?as?in?the?subsection?12.4?Medicines?used?in?heart?failure.? ? The?proposal?is?based?on?the?following?evidence?and?considerations:? ? 1. there? is? robust? evidence? that? thiazide? diuretics? may? have? an? important? role? in? the? prevention?of?heart?failure?(HF)?in?patient?with?hypertension?(Davies?2006,?a?large?RCT?C? ALLHAT.?For?the??description?of?the?study?see?Table?1?at?page?7,?for?the?abstract?of?the? study?see?Annex?C,?reference?17);

?? 2. there?is?less?robust?evidence?that?thiazide?diuretics?may?have?a?role?in?the?treatment?of?HF? in?the?management?of?outpatients?with?mild?HF?(Faris?2006,?a?Cochrane?systematic?review.? For?the?description?of?the?study?see?page?13)?and?as?an?adjunctive?option?to?loop?diuretics? for?patients?with?refractory?oedema?or?not?responsive?to?furosemide?alone?(Dormans?1996,? case?series?study.?For?the?description?of?the?study?see?Table?1?at?page?7).?In?particular?the? study? from? Dormans? showed? that? thiazides? combined? with? furosemide? are? effective? in? reducing?the?body?weight?and?the?oedema?in?patient?with?HF?not?responsive?to?furosemide? alone;

? 3. all?the?guidelines?available?coherently?suggest?to?use?all?classes?of?diuretics?and?thiazides?in? particular?for?the?prevention?of?HF?and?as?an?ancillary?therapy?in?HF?combined?with?loop? diuretics?or?as?single?treatment?in?case?of?mild?HF?(see?Annex?B,?11?guidelines?included).? Keeping? thiazides? diuretics? for? the? prevention? and? treatment? of? HF? (alone? or? in? combination?with?other?diuretics)?will?also?be?consistent?with?most?current?guidelines?in? consideration?of?their?prominent?role?in?the?treatment?of?chronic?hypertension?and?thus?in? the?prevention?of?HF;

? 4. thiazide? diuretics? are? considered? to? be? cost\effective? drugs,? with? a? favourable? profile? in? term?of?balance?between?benefits?and?harms.?? ? 2.?Name?of?the?focal?point?in?WHO?submitting?or?supporting?the?application? Dr.?Suzanne?Hill?was?consulted?in?the?development?of?this?application.? ? 3.?Name?of?the?organization(s)?consulted?and/or?supporting?the?application? CEVEAS,? NHS? Centre? for? the? Evaluation? of? the? Effectiveness? of? Health? Care,? World? Health? Organization? Collaborating? Centre? for? Evidence? Based? Research? Synthesis? and? Guideline? Development?in?Reproductive?Health.?Modena,?Italy.? ? 4.?International?Nonproprietary?Name?(INN,?generic?name)?of?the?medicine?Thiazide? diuretics:? INN? were? taken? from? the? British? National? Formulary? (BNF)? [available? upon? registration? at? the? URL:? http://www.bnf.org.uk/bnf/index.htm],? and? FDA? Physicians'