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期刊来源：JAMA

文献发表时间：2023-11-07

原文链接：https://jamanetwork.com/journals/jama/article-abstract/2811435

关键点内容如下：

问题

哪些药物疗法可改善酒精滥用患者的预后？

调查结果

在这项包括118项临床试验和20976名参与者的系统回顾和荟萃分析中，与安慰剂相比，50 mg/d口服纳曲酮和阿坎酸均可显著改善饮酒相关的结果。

意义

这些发现支持口服纳曲酮（50mg/d）和阿坎酸作为酒精滥用的一线治疗。

摘要内容如下：

重要性

在美国，酒精滥用影响着超过2830万人，并与发病率和死亡率的增加有关。

目的

酒精滥用疗法的疗效和比较疗效。

数据来源

检索PubMed、Cochrane Library、Cochrane Central Trials Registry、PsycInfo、CINAHL和EMBASE，检索时间为2012年11月至2022年9月9日，随后对文献进行系统监测，以确定截至2023年8月14日的相关文章，并于2023年8月14日更新PubMed检索。

研究选择

对于疗效结果，纳入了至少持续12周的随机临床试验。对于不良反应，包括比较药物治疗和报告的健康结果或危害的随机临床试验和前瞻性队列研究。

数据提取和综合

两名评价者评价了每项研究，评估了偏倚风险，并对证据强度进行了分级。荟萃分析采用随机效应模型。对于至少具有中等强度获益证据的药物，计算需要治疗的人数。

主要结局和措施

主要结果是饮酒量。次要转归为机动车事故、损伤、生活质量、功能、死亡率和危害。

结果

数据来自118个临床试验和20976名参与者。为防止1人恢复饮酒，阿坎酸需要治疗的人数为11人（95%CI，1-32），口服纳曲酮需要治疗的人数为18人（95%CI，4-32），剂量为50 mg/d。与安慰剂相比，口服纳曲酮（50 mg/d）与较低的重度饮酒率相关，需要治疗的人数为11（95%CI，5-41）。注射用纳曲酮与30天治疗期内较少的饮酒天数相关，（加权平均差，-4.99天；95%CI，-9.49至-0.49天）阿坎酸的不良反应包括较高的胃肠道不适（腹泻：风险比，1.58；95%CI，1.27-1.97）和纳曲酮（恶心：风险比，1.73；95%可信区间为1.51~1.98；呕吐：风险比为1.53；95%CI，1.23-1.91与安慰剂相比的）。

结论和相关性

结合心理社会干预，这些发现支持口服纳曲酮（50mg/d）和阿坎酸作为酒精滥用的一线药物治疗。

英文原文如下：

Key Points

Question  Which pharmacotherapies are associated with improved outcomes for people with alcohol use disorder?

Findings  In this systematic review and meta-analysis that included 118 clinical trials and 20 976 participants, 50 mg/d of oral naltrexone and acamprosate were each associated with significantly improved alcohol consumption-related outcomes compared with placebo.

Meaning  These findings support oral naltrexone at 50 mg/d and acamprosate as first-line therapies for alcohol use disorder.

Abstract

Importance  Alcohol use disorder affects more than 28.3 million people in the United States and is associated with increased rates of morbidity and mortality.

Objective  To compare efficacy and comparative efficacy of therapies for alcohol use disorder.

Data Sources  PubMed, the Cochrane Library, the Cochrane Central Trials Registry, PsycINFO, CINAHL, and EMBASE were searched from November 2012 to September 9, 2022 Literature was subsequently systematically monitored to identify relevant articles up to August 14, 2023, and the PubMed search was updated on August 14, 2023.

Study Selection  For efficacy outcomes, randomized clinical trials of at least 12 weeks’ duration were included. For adverse effects, randomized clinical trials and prospective cohort studies that compared drug therapies and reported health outcomes or harms were included.

Data Extraction and Synthesis  Two reviewers evaluated each study, assessed risk of bias, and graded strength of evidence. Meta-analyses used random-effects models. Numbers needed to treat were calculated for medications with at least moderate strength of evidence for benefit.

Main Outcomes and Measures  The primary outcome was alcohol consumption. Secondary outcomes were motor vehicle crashes, injuries, quality of life, function, mortality, and harms.

Results  Data from 118 clinical trials and 20 976 participants were included. The numbers needed to treat to prevent 1 person from returning to any drinking were 11 (95% CI, 1-32) for acamprosate and 18 (95% CI, 4-32) for oral naltrexone at a dose of 50 mg/d. Compared with placebo, oral naltrexone (50 mg/d) was associated with lower rates of return to heavy drinking, with a number needed to treat of 11 (95% CI, 5-41). Injectable naltrexone was associated with fewer drinking days over the 30-day treatment period (weighted mean difference, −4.99 days; 95% CI, −9.49 to −0.49 days) Adverse effects included higher gastrointestinal distress for acamprosate (diarrhea: risk ratio, 1.58; 95% CI, 1.27-1.97) and naltrexone (nausea: risk ratio, 1.73; 95% CI, 1.51-1.98; vomiting: risk ratio, 1.53; 95% CI, 1.23-1.91) compared with placebo.

Conclusions and Relevance  In conjunction with psychosocial interventions, these findings support the use of oral naltrexone at 50 mg/d and acamprosate as first-line pharmacotherapies for alcohol use disorder.

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