Anfotericina B lipossomal ou complexo lipídico de anfotericina B: qual é a melhor alternativa entre pacientes com insuficiência renal prévia ou toxicidade inaceitável ao tratamento com anfotericina B convencional?

Abstract

Background and objectives: Lipid formulations of amphotericin B (lipid complex and liposomal) constitute an innovation in antifungal therapy, presenting superior safety profiles when compared with conventional amphotericin B (AmB).¹ However, defining utilization criteria is necessary to reduce the associated economic burden, specially in low and middle income settings. The comparative effectiveness of the different lipid formulations in patients with previous renal impairment or unacceptable toxicity to AmB is not established in clinical practice. We aimed to compare both formulations efficacy and safety in this specific population, in order to contribute to evidencebased decisions. Methods: This systematic review included Medline (Pubmed), Cochrane Central Register of Controlled Trials (CENTRAL), Embase and Lilacs databases. The search terms were a combination of ‘liposomal amphotericin B’ and ‘amphotericin B lipid complex’ terms. Inclusion criteria: randomized clinical trials and observational studies; patients with previous renal impairment or unacceptable toxicity to conventional amphotericin B; treatment comparing L-AmB with ABLC. Two investigators independently screened the search results, assessed trial quality (GRADE) and extracted data. Results: A total of 459 abstracts were screened, and five observational studies were selected for full-text reading. Four studies included patients with normal renal function; only one study evaluated exactly the population of interest: Wade and colleagues² reviewed the medical records of 327 patients and found that creatinine elevation (double of basal value or >1,2 mg/dL) was more than twice as common among ABLC patients versus L-AmB (p=0.020). In contrast, no significant difference was found in clinical relevant outcomes as dialysis (p=0.916) or mortality (p=0.700). Conclusions: The quality of available studies is low. Therefore, we concluded that there is no robust evidence, particularly considering significant outcomes in clinical practice, to embase clinical decisions 270 Posters #HTAiTokyo2016 regarding one or another lipid formulation in this specific scenario. Further studies are necessary to elucidate whether there is a role for choosing between them despite economic value. References: ¹ Safdar A, Ma J, Saliba F, Dupont B, Wingard JR, Hachem RY, et al. Drug-induced nephrotoxicity caused by amphotericin B lipid complex and liposomal amphotericin B: a review and metaanalysis. Medicine (Baltimore) 2010;89(4):236-44. ² Wade R, Chaudhari P, Natoli J, Taylor R, Nathanson B, Horn D. Nephrotoxicity and other adverse events among inpatients receiving liposomal amphotericin B or amphotericin B lipid complex. Diagnostic Microbiology and Infectious Disease 2013; 76(3):361 - 367.