Promoting evidence-based pharmaceutical practice in the community pharmacy using the results of a Cochrane systematic review

Aims

To derive evidence-based guidelines for the treatment of vulvovaginal candidiasis (VVC) in community pharmacy settings using the results of a Cochrane review of the relative effectiveness of oral versus intra-vaginal azole antifungals for the treatment of VVC and, to assess the cost-effectiveness, safety and patient preference of oral versus intra-vaginal anti-fungals.

Method

A systematic review was performed using Cochrane methodology. The selection criteria included: randomised controlled trials (RCTs) published in any language; comparison of at least one oral anti-fungal with one intra-vaginal anti-fungal; and, women (aged 16 years or over) with uncomplicated VVC; a mycological diagnosis of VVC (i.e. a positive culture and / or microscopy for yeast). Odds ratios were pooled using the random effects model. Chi-squared tests with a p-value of less than 0.1 indicated heterogeneity in the results. The results of the review were disseminated to a guideline working party (GWP) whose function was to develop evidence-based guidelines for the treatment of VVC. The guidelines were to be tested in an RCT to compare guideline implementation strategies in the community pharmacy setting. Firstly, the GWP completed a nominal group technique to identify the main issues to be addressed by the guidelines. The results of the systematic review were then considered, together with the results of a systematic review of epidemiological studies to assess the predictive value of symptoms in the diagnosis of VVC. The results of the reviews were then formulated into guideline recommendations and presented in a laminated booklet and laminated flow-chart.

Outcome

Seventeen trials were included in the review, reporting 19 oral versus intra-vaginal anti-fungal comparisons. No statistically significant differences were shown between oral and intra-vaginal anti-fungal treatment for clinical cure at short term (OR 1.00 (95% CI, 0.72 to 1.40)) and long term (OR 1.03 (95% CI, 0.72 to 1.49)) follow-up. No statistically significant differences for mycological cure were observed between oral and intra-vaginal treatment at short term (OR 1.20 (95% CI, 0.87 to 1.65)) or long term follow-up (OR 1.30 (95% CI, 0.99 to 1.71)). Two trials each reported one withdrawal from treatment due to an adverse reaction. Treatment preference data were poorly reported. The guidelines recommended that the choice of anti-fungal should be based upon safety, effectiveness and cost. The guidelines also stated that the customer's wishes and preferences should also be considered.

Conclusions

The review showed that no differences exist in terms of the relative effectiveness (measured as clinical and mycological cure) of anti-fungals administered by the oral and intra-vaginal routes for the treatment of uncomplicated vaginal candidiasis. The selection of an anti-fungal for the treatment of VVC should, therefore, be based upon safety, cost and patient preference.

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