Christoph Stettler 1 , 2 , 3 , Sabin Allemann 1 , 2 , Simon Wandel 1 , Adnan Kastrati 4 , Marie Claude Morice 5 , Albert Schömig 4 , Matthias E Pfisterer 6 , Gregg W Stone 7 , Martin B Leon 7 , José Suárez de Lezo 8 , Jean-Jacques Goy 9 , Seung-Jung Park 10 , Manel Sabaté 11 , Maarten J Suttorp 12 , Henning Kelbaek 13 , Christian Spaulding 14 , Maurizio Menichelli 15 , Paul Vermeersch 16 , Maurits T Dirksen 17 , Pavel Cervinka 18 , Marco De Carlo 19 , Andrejs Erglis 20 , Tania Chechi 21 , Paolo Ortolani 22 , Martin J Schalij 23 , Peter Diem 2 , Bernhard Meier 24 , Stephan Windecker 24 , 25 , Peter Jüni , 1 , 25
29 August 2008
Objective To compare the effectiveness and safety of three types of stents (sirolimus eluting, paclitaxel eluting, and bare metal) in people with and without diabetes mellitus.
Design Collaborative network meta-analysis.
Data sources Electronic databases (Medline, Embase, the Cochrane Central Register of Controlled Trials), relevant websites, reference lists, conference abstracts, reviews, book chapters, and proceedings of advisory panels for the US Food and Drug Administration. Manufacturers and trialists provided additional data.
Review methods Network meta-analysis with a mixed treatment comparison method to combine direct within trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. Overall mortality was the primary safety end point, target lesion revascularisation the effectiveness end point.
Results 35 trials in 3852 people with diabetes and 10 947 people without diabetes contributed to the analyses. Inconsistency of the network was substantial for overall mortality in people with diabetes and seemed to be related to the duration of dual antiplatelet therapy (P value for interaction 0.02). Restricting the analysis to trials with a duration of dual antiplatelet therapy of six months or more, inconsistency was reduced considerably and hazard ratios for overall mortality were near one for all comparisons in people with diabetes: sirolimus eluting stents compared with bare metal stents 0.88 (95% credibility interval 0.55 to 1.30), paclitaxel eluting stents compared with bare metal stents 0.91 (0.60 to 1.38), and sirolimus eluting stents compared with paclitaxel eluting stents 0.95 (0.63 to 1.43). In people without diabetes, hazard ratios were unaffected by the restriction. Both drug eluting stents were associated with a decrease in revascularisation rates compared with bare metal stents in people both with and without diabetes.
Conclusion In trials that specified a duration of dual antiplatelet therapy of six months or more after stent implantation, drug eluting stents seemed safe and effective in people both with and without diabetes.