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Guía de Práctica Clínica - No GES

Influenza

Recomendación T1 / Juicio del Panel y Evidencia

T1.- En adultos, niños y niñas con influenza en estado crítico, el Ministerio de Salud sugiere que el uso de oseltamivir se extienda por 5 días en vez de por 10 días.

Comentarios del Panel de Expertos:
►En la actualidad no existe evidencia respecto de los efectos de tratamientos extendidos con oseltamivir. Sin embargo, pudieran existir situaciones clínicas en que terapias extendidas pudieran tener algún beneficio, como por ejemplo en pacientes inmunosuprimidos.

El Panel de Expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.

A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.

 1.- ¿El problema es una prioridad?
No Probablemente no Probablemente sí Varía No lo sé

El problema ha sido definido como prioritario del Departamento de Enfermedades Transmisibles del Ministerio de Salud.

 2.- ¿Qué tan significativos son los efectos deseables anticipados?
Trivial Pequeño Moderado Grande Varía No lo sé

No lo sé: El equipo elaborador de la Guía consideró que no contaba con suficiente información para emitir un juicio respecto a la significancia de los efectos deseables de «usar oseltamivir por 5 días» en comparación a «usar oseltamivir por 10 días».

Entregar tratamiento con oseltamivir por 10 días comparado con entregar por sólo 5 días para pacientes críticos con diagnóstico de influenza.

 

Pacientes

Pacientes críticos (adultos, niños y niñas) con diagnóstico de influenza

 

Intervención

Entregar tratamiento con oseltamivir por 10 días.

 

Comparación

Entregar por sólo 5 días.

 

Desenlaces

Efecto

Certeza de la evidencia

(GRADE)

Mensajes clave en términos sencillos

 
 

Impacto clínico

No se encontraron estudios relevantes para la pregunta.

 

GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
Fecha de elaboración de la tabla: Octubre, 2018.

Referencia

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Búsqueda y Síntesis de Evidencia

 3.- ¿Qué tan significativos son los efectos indeseables anticipados?
Grande Moderado Pequeño Trivial Varía No lo sé

No lo sé: El equipo elaborador de la Guía consideró que no contaba con suficiente información para emitir un juicio respecto a la significancia de los efectos indeseables de «usar oseltamivir por 5 días» en comparación a «usar oseltamivir por 10 días».

Evidencia de investigación

Entregar tratamiento con oseltamivir por 10 días comparado con entregar por sólo 5 días para pacientes críticos con diagnóstico de influenza.

 

Pacientes

Pacientes críticos (adultos, niños y niñas) con diagnóstico de influenza

 

Intervención

Entregar tratamiento con oseltamivir por 10 días.

 

Comparación

Entregar por sólo 5 días.

 

Desenlaces

Efecto

Certeza de la evidencia

(GRADE)

Mensajes clave en términos sencillos

 
 

Impacto clínico

No se encontraron estudios relevantes para la pregunta.

 

GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
Fecha de elaboración de la tabla: Octubre, 2018.

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Búsqueda y Síntesis de Evidencia

 4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
Muy baja Baja Moderada Alta Ningún estido incluído

Muy Baja: Existe considerable incertidumbre respecto del efecto de «usar oseltamivir por 5 días» en comparación a «usar oseltamivir por 10 días».

 5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
Incertidumbre o variabilidad importantes Posiblemente hay incertidumbre o variabilidad importantes Probablemente no hay incertidumbre ni variabilidad importantes No hay variabilidad o incertidumbre importante

Posiblemente hay incertidumbre o variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el equipo elaborador de la Guía consideró que posiblemente existe incertidumbre o variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «usar oseltamivir por 5 días» y «usar oseltamivir por 10 días».

Consideraciones Adicionales

No se identificó evidencia directa del uso de oseltamivir en pacientes adultos críticos con diagnóstico de influenza.

Para responder esta pregunta se utilizó evidencia indirecta proveniente de estudios del uso de oseltamivir en pacientes ambulatorios.

Un estudio transversal realizado en un hospital de base militar de Luisiana, Estados Unidos, que atiende a miembros del ejército y sus familiares utilizó una encuesta para evaluar la percepción de los pacientes sobre el uso, eficacia y seguridad de oseltamivir para el tratamiento de la influenza tipo A y B.

El estudio utilizó una encuesta con respuestas abiertas y fueron dirigidas a pacientes adultos y a cuidadores de niños.

Los resultados de acuerdo a lo que opinan los pacientes son los siguientes:
-Si el curso de la gripe se estimó que duraría 10 días, entonces los pacientes reportaron que los que recibieron oseltamivir se recuperarían en promedio 4 a 5 días antes que los pacientes que no fueron tratados.
-Los pacientes estarían dispuestos a pagar de su bolsillo en promedio para acortar la duración de la gripe en 1 día US$28.01 ($18.000 aprox), en 3 días US$30.84 ($20.340 aprox) y en 5 días US$38.37 (25.00 aprox)
-Al final de la encuesta el fabricante del medicamento entrego una lista de eventos adversos para que los participantes seleccionaran aquellos que podrían influir para decidir dejar de tomar el medicamento:
-El daño renal y en el hígado fueron los más frecuentes seleccionados por los participantes. Los de menor importancia fueron dificultad para respirar y sentirse aturdido.

Referencia:
1. Schauer SG, Varney SM, Aden JK, Bebarta VS. Patient Perceptions of Oseltamivir for the Treatment of Influenza. South Med J. 2016;109(8):477–80.

Búsqueda y Síntesis de Evidencia

 6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
Favorece la comparación Probablemente favorece la comparación No favorece la intervención ni la comparación Probablemente favorece la intervención Favorece la intervención Varía No lo sé

No lo sé: El equipo elaborador de la Guía consideró que no contaba con suficiente información para emitir un juicio respecto al balance entre efectos deseables e indeseables.

 7.- ¿Qué tan grandes son los recursos necesarios (costos)?
Costos extensos Costos moderados Costos y ahorros despreciables Ahorros moderados Ahorros extensos Varía No lo sé

No lo sé: El equipo elaborador de la Guía consideró que no contaba con suficiente información para emitir un juicio respecto a la magnitud de los costos y los ahorros de «usar oseltamivir por 5 días» versus «usar oseltamivir por 10 días».

Consiereaciones Adicionales

El panel considera que se desconocen otros riesgos del medicamento.

Evidencia de investigación

A continuación se muestran los precios referenciales de las prestaciones sanitarias de “usar oseltamivir por 10 días y usar oseltamivir por 5 días”, de modo que el equipo elaborador de la Guía se pudiese pronunciar al respecto.

Ítem

INTERVENCION

PRECIO

Medicamento

1Oseltamivir 75mg

 

 

 

2Oseltamivir 75mg

 

2Oseltamivir solución 12mg/mL

$2. 052 por comprimido

Cada caja contiene 10 comprimidos

 

$539 por comprimido

 

$18.600 frasco

Referencias:
1.- Mercado Público +IVA
2. – CENABAST

Búsqueda y Síntesis de Evidencia

 8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
Favorece la comparación Probablemente favorece la comparación No favorece la intervención ni la comparación Probablemente favorece la intervención Favorece la intervención Varía Ningún estudio incluido

Ningún estudio incluido: No se encontraron estudios que respondieran la preguntan de interés.

 9.- ¿Cuál sería el impacto en equidad en salud?
Reducido Probablemente reducido Probablemente ningún impacto Probablemente aumentado Aumentado Varía No lo sé

Probablemente ningún impacto: El equipo elaborador de la Guía consideró que probablemente no tendría ningún impacto en la equidad en salud si se recomendase «usar oseltamivir por 5 días», dado que identificó grupos o contextos que actualmente tiene barreras de acceso importantes, ya sea en términos económicos, geográficos u otros.

 10.- ¿La intervención es aceptable para las partes interesadas?
No Probablemente no Probablemente sí Varía No lo sé

Varía: El equipo elaborador de la Guía considera que existen componentes que pueden afectar de distinta manera la aceptación de la intervención “usar oseltamivir por 5 días» por las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos servicios de salud, pacientes, cuidadores, seguros de salud, otros).

 11.- ¿Es factible implementar la intervención?
No Probablemente no Probablemente sí Varía No lo sé

Sí: El equipo elaborador de la Guía consideró que «usar oseltamivir por 5 días» SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.