Mixed Individual-Aggregate Data on All-Cause Mortality in Bullous Pemphigoid

Abstract

The 1-year standardized mortality ratio (SMR) of bullous pemphigoid (BP) has been reported as 2.15 to 7.56 and lower in the US than in Europe.OBJECTIVE To estimate the worldwide 1-year SMR of BP.DATA SOURCES PubMed, Embase, Cochrane Library, Google Scholar, Lissa, and gray literature (eg, medRxiv) were screened for studies of BP published from inception to June 10, 2020, with review of reference lists. STUDY SELECTIONRetrospective and prospective studies reporting 1-year all-cause mortality rate in patients with BP and providing age statistics (eg, mean [SD]).DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted the data. The 1-year SMR was computed in studies reporting 1-year mortality by combining information on age obtained from studies with aggregate data and individual data. Risk of representativity, misclassification, and attrition bias were assessed by a custom tool. MAIN OUTCOMES AND MEASURESThe primary end point was the worldwide 1-year SMR. Secondary analysis included comparison of 1-year SMRs between continents in a meta-regression.RESULTS Three studies were performed in the US (n = 260), 1 in South America (n = 45), 16 in Asia (n = 1903), and 36 in Europe (n = 10 132) for a total of 56 unique studies and 12 340 unique patients included in the meta-analysis (mean [SD] age, 77.3 [12.7] years; 55.9% women). The mean (SD) patient age in the United States was 75.6 (13.7) years; in Asia, 73.8 (13.6) years; and in Europe, 78.1 (12.3) years. The worldwide 1-year SMR was estimated at 2.93 (95% CI, 2.59-3.28; I 2 = 85.6%) for all 56 studies. The 1-year SMR in the US was 2.40 (95% CI, 0.89-3.90; I 2 = 86.3%) for 3 studies; in Asia, 3.53 (95% CI, 2.85-4.20; I 2 = 86.3%) for 16 studies; and in Europe, 2.77 (95% CI, 2.35-3.19; I 2 = 86.3%) for 36 studies. After adjustment on the expected 1-year mortality rate, the European 1-year SMR did not differ significantly from the 1-year SMR in the United States (−0.48 vs Europe; 95% CI, −2.09 to 1.14; P = .56) and Asia (0.51 vs Europe; 95% CI, −0.56 to 1.58; P = .35). Risk of attrition bias was high (>10% censorship) in 16 studies (28.6%), low in 16 (28.6%), and unclear in 24 (42.9%). Only 4 studies (7.1%) had a sampling method guaranteeing the representativity of BP cases in a population.CONCLUSIONS AND RELEVANCE Although heterogeneity was high and overall quality of follow-up was poor, this meta-analysis confirms the high mortality rate among patients with BP.

International multicentre observational study to assess the efficacy and safety of a 0·5 mg kg −1 per day starting dose of oral corticosteroids to treat bullous pemphigoid

“…Patients were followed according to the schedule proposed in the EADV guidelines. Side‐effects of treatment were assessed, and their severity was graded according to the standard criteria of the World Health Organization 23,24 . Patients were followed for 1 year after BP diagnosis.…”

Immunopathology and Immunotherapy of Inflammatory Skin Diseases

“…Bullous pemphigoid is thought to be associated with neurologic disorders including dementia, multiple sclerosis, and Parkinson’s disease ( 85 ). Because it preferentially occurs in older adults with comorbidities and requires long-term use of systemic corticosteroids and immunosuppressive drugs, patients with bullous pemphigoid have a higher mortality rate (approximately 20%) than healthy older adults ( 86 ).…”

Cause‐specific mortality in people with bullous pemphigoid and pemphigus vulgaris: a systematic review and meta‐analysis

“…Future studies also require appropriate control groups, longer follow‐up and a measure of person‐years in order to calculate mortality rates. A recent systematic review on all‐cause mortality in BP that included 56 studies reported that the overall quality of follow‐up was poor 8 . It is pertinent that researchers improve the reporting of mortality measures for these serious autoimmune blistering disorders.…”