Slee A, et al. - This is the largest contemporary review of pharmacological agents used by network analysis for the treatment of generalized anxiety disorder. Due to the cost and resource constraints of psychological alternatives, pharmacological treatment is often the first choice for clinicians, researchers analyzed the comparative information for the multiple drug choices available. Findings suggested that there were several effective treatment choices for generalized anxiety disorder across classes of medication. The failure of the initial pharmacological therapy could not be a reason to abandon a strategy for pharmacological treatment.

Methods

• Investigators conducted a systematic review and network meta-analysis on randomised trials in adult outpatients with generalized anxiety disorder identified from MEDLINE, Web of Science, Cochrane Library,ClinicalTrials.gov, Chinese National Knowledge Infrastructure (CNKI), Wanfang data, Drugs@FDA and commercial pharmaceutical registries.
• For this analysis, placebo and active control trials were involved.
• From all manuscripts and reports, data were extracted.
• Efficacy (mean difference [MD] in change in Hamilton Anxiety Scale Score) and acceptability (study discontinuations for any cause) were primary outcomes.
• Using network meta-analyses with random effects, they estimated summary mean treatment differences and odds ratios.

Results

• Between January 1, 1994 and August 1, 2017, studies were published in which 1992 potential studies were screened for inclusion.
• This analysis is based on 89 trials, which involved 25,441 subjects randomly assigned to 22 different active drugs or placebo.
• Investigators found that duloxetine (MD −3·13, 95% credible interval [CrI] −4·13 to −2·13), pregabalin (MD −2·79, 95% CrI −3·69 to −1·91), venlafaxine (MD −2·69, 95% CrI −3·50 to −1·89), and escitalopram (MD −2·45, 95% CrI −3·27 to −1·63) were more efficacious than placebo with relatively good acceptability.
• In addition, mirtazapine, sertraline, fluoxetine, buspirone, and agomelatine were found to be efficacious and well tolerated but these findings were limited by small sample sizes.
• They discovered that quetiapine (MD −3·60 95% CrI −4·83 to −2·39) had the largest impact on HAM-A but it was poorly tolerated (odds ratio 1·44, 95% CrI 1·16–1·80) when compared with placebo.
• Paroxetine and benzodiazepines were also efficient but poorly tolerated in comparison to placebo.
• The risk of reporting bias was considered low and all completed studies were included to avoid publication bias when possible.