Comparative efficacy and safety of high-dose rifamycin regimens for tuberculosis treatment: a Bayesian network meta-analysis

Comparison of first-line chemotherapy regimens in unresectable locally advanced or metastatic pancreatic cancer: a systematic review and Bayesian network meta-analysis

BackgroundProbiotics have been shown to reduce the risk of mortality and necrotizing enterocolitis (NEC) in very low birth weight (VLBW) neonates. The probiotic species with the maximal benefits in neonates from low- and middle-income countries are unknown.ObjectiveTo identify the strain of probiotics with the maximum benefit in preventing neonatal mortality, sepsis, and NEC using the Bayesian network meta-analysis.Search methodsWe searched Medline via PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). We also hand-searched reference lists of previous systematic reviews to identify eligible studies.Selection criteriaRandomized controlled trials (RCTs) from LMICs comparing enteral supplementation of one or more probiotics with another probiotic species or placebo were included.Data collection and analysisTwo authors screened the studies, extracted the data, and examined the risk of bias using the Cochrane risk of bias 2 (RoB 2) tools. Bayesian network meta-analysis was performed using the “BUGSnet” package in R and RStudio (version 1.4.1103). The confidence in the findings was assessed using the Confidence in Network Meta-analysis (CINeMA) web application.ResultsTwenty-nine RCTs enrolling 4,906 neonates and evaluating 24 probiotics were included. Only 11 (38%) studies had a low risk of bias. All the studies compared the probiotics with a placebo; none had a head-to-head comparison of different probiotic species. Also, only one study each had evaluated most probiotic regimens. When compared to placebo, the combination of B longum, B bifidum, B infantis, and L acidophilus may reduce the risk of mortality (relative risk [RR] 0.26; 95% credible interval [CrI] 0.07 to 0.72), sepsis (RR 0.47; 95% CrI 0.25 to 0.83), and NEC (RR 0.31; 95% CrI 0.10 to 0.78) but the evidence is very uncertain. There is low certainty evidence that the single probiotic species, B lactis, could reduce the risk of mortality (RR 0.21; 0.05 to 0.66) and NEC (RR 0.09; 0.01 to 0.32).ConclusionGiven the low to very low certainty of evidence for the efficacy of the two probiotics found to reduce mortality and necrotizing enterocolitis, no firm conclusions can be made on the optimal probiotics for use in preterm neonates in low- and middle-income countries.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022353242, identifier: CRD42022353242.

Network meta-analysis of antidepressants

A Bayesian network meta-analysis for a head-to-head comparison of the therapeutic efficacy and safety of currently used corticosteroids in sepsis. A total of 35 eligible randomized controlled trials of corticosteroid use in sepsis. The present Bayesian network meta-analysis included 8,859 patients with sepsis. Randomized controlled trials were screened from PubMed, Embase, and the Cochrane Library up to December 28, 2019. A head-to-head comparison of the therapeutic efficacy and safety between the different categories of corticosteroids from the trials was conducted by Bayesian network meta-analysis. An empirical Bayesian meta-regression and a post hoc Bayesian network meta-analysis were performed to explore the appropriate dose and therapeutic duration of steroids for sepsis. A total of 35 randomized controlled trials including 8,859 patients with sepsis were enrolled in the final analysis. Bayesian network meta-analysis revealed that methylprednisolone and dexamethasone might be more effective in reducing short-term mortality in sepsis than placebo: methylprednisolone versus placebo (relative risk, 0.65, 95% credible interval 0.40-0.93), dexamethasone versus placebo (relative risk, 0.42, 95% credible interval, 0.24-0.84). Hydrocortisone and hydrocortisone plus fludrocortisone were superior to placebo in days to shock resolution (e-Table 5, Supplemental Digital Content 1, http://links.lww.com/CCX/A150): hydrocortisone versus placebo (mean difference, -1.70, 95% credible interval, -2.83 to -0.92), hydrocortisone plus fludrocortisone versus placebo (mean difference, -2.54, 95% credible interval, -4.19 to -0.84). Hydrocortisone was superior to placebo in reducing the length of stay in the ICU (mean difference, -1.43, 95% credible interval, -3.36 to -0.15). Methylprednisolone was superior to placebo in improving ventilation-free days (mean difference, 7.71, 95% credible interval, 1.15-14.42). In addition, further analysis indicated that the optimal therapeutic dosage was 200-400 mg per day of hydrocortisones or equivalents (relative risk, 0.83, 95% credible interval, 0.64-0.98), and the appropriate therapeutic duration was 4-7 days (relative risk, 0.78; 95% credible interval, 0.57-0.96). This study provided moderate evidence that the dosage of 200-400 mg per day of hydrocortisone or equivalent for 4-7 days was most likely to benefit septic patients.

Background:As a debilitating neurodegenerative disease, neovascular age-related macular degeneration (nAMD) accounts for more than 90% of severe visual loss or legal blindness among AMD patients. Anti-vascular endothelial growth factor (VEGF) had been applied widely in nAMD treatment. To date, debate regarding efficacy and safety still exists among different anti-VEGF regimens as management of nAMD. To provide substantial evidence for clinical nAMD treatment, this study ranks the priority of anti-VEGF regimens via Bayesian network meta-analysis (NMA), comparing data collected from randomized controlled trials (RCTs).Methods:We searched PubMed Central, MEDLINE Ovid, Embase Ovid, ISRCTN, ICTRP and ClinicalTrials. gov from a database established until 1 April 2019 systematically for anti-VEGF regimens. Bayesian NMA with random-effect was conducted to compare efficacy and safety and rank priority of anti-VEGF regimens. The primary efficacy and safety outcomes were the proportion of patients gaining 15 or more letters, and the incidence of arterial thromboembolic (ATC) events. The effect measure is the standard mean difference (SMD), or the odds ratio (OR) with their 95% confidence interval (CI). The study protocol is registered with PROSPERO, number CRD42019132243.Results:We obtained 6467 citations and identified 29 RCTs including 13,596 participants; 86% of these trials were low risk or of uncertain risk bias. In NMA, ORs compared with sham injection for the proportion of patients gaining 15 or more letters (12,699 participants from 23 trials) ranged from 4.05 [95% Bayesian credible interval (CrI) 1.62–10.11] for ranibizumab quarterly regimen to 8.57 (95% CrI 4.66–15.73) for a ranibizumab treat-and-extend regimen. No difference was found between sham injection and anti-VEGF regimens for ATC events (11,500 participants from 18 trials). Results for the primary outcome did not substantially change in sensitivity analyses after removing studies at high risk of bias and small sample size (n < 100), respectively.Conclusion:The treat-and-extend regimen of ranibizumab and aflibercept are the preferred anti-VEGF regimens for nAMD. Bevacizumab treat-and-extend regimens need more head-to-head comparisons with other regimens or sham injection for advanced application. The treat-and-extend regimen proved to be the most effective regimen for each anti-VEGF drug in the NMA. Pegaptanib every 6 weeks and Conbercept quarterly are unable to satisfy the best corrected visual acuity (BCVA) improvement requirement of nAMD patients.

A wide range of ablative and non-surgical therapies are available for treating small hepatocellular carcinoma in patients with very early or early-stage disease and preserved liver function. To review and compare the effectiveness of all current ablative and non-surgical therapies for patients with small hepatocellular carcinoma (≤ 3 cm). Systematic review and network meta-analysis. Nine databases (March 2021), two trial registries (April 2021) and reference lists of relevant systematic reviews. Eligible studies were randomised controlled trials of ablative and non-surgical therapies, versus any comparator, for small hepatocellular carcinoma. Randomised controlled trials were quality assessed using the Cochrane Risk of Bias 2 tool and mapped. The comparative effectiveness of therapies was assessed using network meta-analysis. A threshold analysis was used to identify which comparisons were sensitive to potential changes in the evidence. Where comparisons based on randomised controlled trial evidence were not robust or no randomised controlled trials were identified, a targeted systematic review of non-randomised, prospective comparative studies provided additional data for repeat network meta-analysis and threshold analysis. The feasibility of undertaking economic modelling was explored. A workshop with patients and clinicians was held to discuss the findings and identify key priorities for future research. Thirty-seven randomised controlled trials (with over 3700 relevant patients) were included in the review. The majority were conducted in China or Japan and most had a high risk of bias or some risk of bias concerns. The results of the network meta-analysis were uncertain for most comparisons. There was evidence that percutaneous ethanol injection is inferior to radiofrequency ablation for overall survival (hazard ratio 1.45, 95% credible interval 1.16 to 1.82), progression-free survival (hazard ratio 1.36, 95% credible interval 1.11 to 1.67), overall recurrence (relative risk 1.19, 95% credible interval 1.02 to 1.39) and local recurrence (relative risk 1.80, 95% credible interval 1.19 to 2.71). Percutaneous acid injection was also inferior to radiofrequency ablation for progression-free survival (hazard ratio 1.63, 95% credible interval 1.05 to 2.51). Threshold analysis showed that further evidence could plausibly change the result for some comparisons. Fourteen eligible non-randomised studies were identified (n ≥ 2316); twelve had a high risk of bias so were not included in updated network meta-analyses. Additional non-randomised data, made available by a clinical advisor, were also included (n = 303). There remained a high level of uncertainty in treatment rankings after the network meta-analyses were updated. However, the updated analyses suggested that microwave ablation and resection are superior to percutaneous ethanol injection and percutaneous acid injection for some outcomes. Further research on stereotactic ablative radiotherapy was recommended at the workshop, although it is only appropriate for certain patient subgroups, limiting opportunities for adequately powered trials. Many studies were small and of poor quality. No comparative studies were found for some therapies. The existing evidence base has limitations; the uptake of specific ablative therapies in the United Kingdom appears to be based more on technological advancements and ease of use than strong evidence of clinical effectiveness. However, there is evidence that percutaneous ethanol injection and percutaneous acid injection are inferior to radiofrequency ablation, microwave ablation and resection. PROSPERO CRD42020221357. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme (NIHR award ref: NIHR131224) and is published in full in Health Technology Assessment; Vol. 27, No. 29. See the NIHR Funding and Awards website for further award information.

ObjectivesTo systematically compare the effects of various antithrombotic strategies on prespecified outcomes including 28-day all-cause mortality (primary outcome), major thrombotic events and major bleeding events (secondary outcomes) in adult COVID-19 patients.DesignSystematic review and Bayesian network meta-analysis (NMA).Data sourcesPubMed, Web of Science, Embase, Cochrane Library and ClinicalTrials.gov up to February 2024.Eligibility criteriaWe included randomised controlled trials (RCTs; published in English) comparing different antithrombotic strategies (eg, anticoagulants, antiplatelet (AP) agents, fibrinolytics or combinations) in adults (aged≥18 years) with laboratory-confirmed SARS-CoV-2 infection. Eligible trials had at least one active antithrombotic arm versus another strategy or standard care.Data extraction and synthesisTwo reviewers independently extracted data using a standardised form; disagreements were resolved by consensus or third-party adjudication. Bayesian NMA was performed using Markov chain Monte Carlo methods with random/fixed effects models selected by the deviance information criterion. The risk of bias (RoB) was assessed using the Cochrane Collaboration’s tool. The confidence in NMA framework was used to assess the quality of evidence.Results35 RCTs that randomly assigned 39 949 participants were included in the main analysis. Primary outcome: evidence of low to moderate certainty suggested that, compared with standard of care (SoC), both prophylactic-dose anticoagulation (PA) (risk ratio (RR) 0.71, 95% credible interval (CrI) 0.44 to 0.99) and therapeutic-dose anticoagulation (TA; RR 0.65, 95% CrI 0.38 to 0.94) reduced the 28-day all-cause mortality. Secondary outcomes: TA (RR 0.19, 95% CrI 0.09 to 0.31), TA+AP (RR 0.27, 95% CrI 0.05 to 0.95), PA (RR 0.33, 95% CrI 0.18 to 0.53) and AP+PA (RR 0.52, 95% CrI 0.25 to 0.94) were effective in reducing major thrombotic events. AP was associated with an increased risk of major bleeding events (RR 2.27, 95% CrI 1.01 to 5.07). Subgroup analyses by hospitalisation status showed that PA significantly reduced 28-day mortality versus SoC (RR 0.52, 95% CrI 0.26 to 0.90) for non-hospitalised patients, whereas no strategies showed significant benefit in hospitalised patients. Subgroup analysis based on severity of hospitalised patients indicated that TA was more favourable than PA in decreasing the 28-day mortality in non-critically ill patients (fixed-effect model: RR 0.75, 95% CI 0.61 to 0.91; random-effect model: RR 0.71, 95% CI 0.48 to 1.05), but for critically ill patients, all antithrombotic strategies showed no significant difference.ConclusionsOur NMA indicates that both PA and TA reduced the 28-day all-cause mortality of adult COVID-19 patients. However, subgroup analyses revealed substantial heterogeneity, and the benefit may differ across hospitalisation status and disease severity.PROSPERO registration numberCRD42022355213.

Comparative Efficacy and Safety of Gemtuzumab Ozogamicin (GO) Plus Daunorubicin-Cytarabine Combination and Comparators As Induction Therapy for Newly Diagnosed Acute Myeloid Leukemia

Background Left atrial appendage occlusion (LAAO) is a viable alternative to oral anticoagulation for stroke prevention in patients with atrial fibrillation (AF), particularly those at high risk of thromboembolism or bleeding. This study evaluates the comparative efficacy and safety of various antithrombotic regimens following LAAO. Objectives To compare the efficacy and safety of various antithrombotic regimens, including aspirin(ASA), direct oral anticoagulants (DOACs), Warfarin, dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), and other combination regimens (e.g., DOAC+ASA, NOAC+APT), in preventing stroke or transient ischemic attack (TIA) while minimizing bleeding and mortality after LAAO. Methods A systematic search was conducted in PubMed, Embase, Scopus, Cochrane Library, and Web of Science for studies published up to November 1, 2024. Studies included adult patients who underwent left atrial appendage occlusion (LAAO) for stroke prevention, typically in the context of AF. Bayesian network meta-analysis was performed using the BUGSnet package in RStudio, applying a random-effects model. Outcome estimates were reported as risk ratios (RR) with 95% credible intervals (CrI) relative to no therapy. Interventions were ranked based on surface under the cumulative ranking curve (SUCRA) values and higher SUCRA values indicate greater efficacy. Results The analysis included 28 studies, comprising 65,229 patients who received different antithrombotic regimens with post-LAAO status. Study findings indicate that NOAC (RR: 0.13, 95% CrI: 0.01–0.75; SUCRA: 82.61%) demonstrated the highest efficacy in reducing stroke/TIA incidence compared to no therapy, followed by NOAC+APT (RR: 0.13, 95% CrI: 0.00–1.37; SUCRA: 75.47%), DOAC+ASA (RR: 0.20, 95% CrI: 0.01–1.20; SUCRA: 69.12%), and DOAC (RR: 0.25, 95% CrI: 0.02–1.29; SUCRA: 58.82%) respectively. For reducing all-cause mortality, DOAC+ASA ranked highest (RR: 0.27, 95% CrI: 0.02–0.81; SUCRA: 83.16%), followed by DOAC (RR: 0.28, 95% CrI: 0.04–0.83; SUCRA: 80.39%), DOAC+APT (RR: 0.36, 95% CrI: 0.03–1.23; SUCRA: 65.27%), Warfarin+ASA (RR: 0.39, 95% CrI: 0.04–1.26; SUCRA: 60.92%), and NOAC (RR: 0.38, 95% CrI: 0.03–1.95; SUCRA: 57.07%) respectively. NOAC+APT (RR: 0.02, 95% CrI: 0.00–0.23; SUCRA: 91.56%) ranked highest for reducing major bleeding events followed by NOAC (RR: 0.04, 95% CrI: 0.01–0.26; SUCRA: 86.4%), DOAC (RR: 0.05, 95% CrI: 0.01–0.32; SUCRA: 79.28%), and Warfarin (RR: 0.05, 95% CrI: 0.01–0.34; SUCRA: 73.64%) respectively. Conclusion NOACs demonstrated the highest efficacy in reducing stroke/TIA among all antithrombotic regimens in AF patients with post-LAAO status, while NOAC+APT showed the lowest risk of major bleeding. DOAC+ASA and DOAC also provided significant benefits in reducing all-cause mortality. These findings elucidate the potential of NOAC-based regimens for optimizing outcomes of post-LAAO status in AF patients.Forest plot of Stroke/TIA incidencesForest plot of major bleeding events

Systematic Review and Network Meta-Analysis of the Efficacy and Safety of Antithrombotic Options following Open Surgical Revascularization for Peripheral Arterial Disease.

Study question What is the long-term impact on uterine volume of a childhood and adolescent, and young adult (AYA) exposure to chemotherapy? Summary answer Compared to the control group, uterine volume was clinically significantly decreased after chemotherapy and even more after radio-chemotherapy. What is known already Uterine damage is well-described after pelvic radiotherapy or total body irradiation (TBI) with decreased uterine volume and high obstetrical morbidity. Few studies have reported smaller uterus in AYA cancer survivors treated with chemotherapy only. In these studies, uterus volume was mostly assessed by a transabdominal and/or transvaginal ultrasonography, and primary diagnosis, age at treatment and chemotherapy regimen were heterogeneous. The uterine impact of chemotherapy is still little investigated. Study design, size, duration A systematic review and meta-analysis on comparative studies. Searches were conducted on Medline, Embase and the Cochrane Library from 1990 to April 2023, using the main following search terms: cancer survivors, bone marrow transplantation, chemotherapy, radiotherapy, uterine volume. All studies reporting uterine volume in adult females who have received chemotherapy and/or radiotherapy during childhood and AYA &amp;lt; 25 years were included. Participants/materials, setting, methods Two independent reviewers carried out the study selection, the bias assessment using the ROBINS-I tool and data extraction. The primary outcome was the uterine volume in mL. A Bayesian network meta-analysis (NMA) with meta-regression on parity and serious risk of bias was performed using a random-effects model. Furthermore sensitivity analyses were performed. Therapies were ranked by the surface under the cumulative ranking curve (SUCRA). Differences in means (MD) with 95% credible intervals (CrI) are reported. Main results and the role of chance After review of 2 328 abstracts, 4 studies were selected for the meta-analysis. Uterine volume was assessed through ultrasonography in three articles and magnetic resonance imaging in one. Uterine volume data were available for 245 females after chemotherapy, 153 after radio-chemotherapy and 257 without cancer females (controls). SUCRA were 0.980 for control, 0.510 for chemotherapy and 0.009 for radio-chemotherapy. One study did not display data by parity (n = 165) and had a serious risk of bias, and was excluded in sensitivity analysis. SUCRA showed the same ranking order. In nulliparous females, compared to the control group (n = 152), uterine volume was decreased in the chemotherapy group (n = 138, MD = -12 mL; 95% CrI, -33, 5.7), and even more in the radio-chemotherapy group (n = 97, MD= -30 mL; 95% Crl -50, -13). In parous females, compared to the control group (n = 41), the decrease in the uterine volume tended to be similar in chemotherapy and radio-chemotherapy groups (MD = -27 mL; 95% CrI, -54, 3.2 with n = 43 and -30 mL; 95% CrI, -50, -13 with n = 19, respectively). Limitations, reasons for caution The own responsibility of chemotherapy for inducing uterine damage is hard to be asserted because of the heterogeneity of radiology assay, and of the diversity of chemotherapy regimens, the lack of data concerning the Cyclophosphamide Equivalent dose, and about the hormonal status at the time of the uterine evaluation. Wider implications of the findings Our results suggest a high probability that a childhood and AYA exposure to chemotherapy could induce uterine damage. Further studies are needed to evaluate the potential obstetrical impact of uterine damage caused by chemotherapy alone. Trial registration number PROSPERO CRD42023440219

Diabetic peripheral neuropathy (DPN) is a most common devitalizing complication of diabetes mellitus, which is primarily characterized by sensory loss, paresthesia, prickling, pain, or allodynia. To evaluate the relative efficacy and safety of the interventions used in the DPN pain management and rank their order. A systematic review and Bayesian network meta-analysis (NMA). Randomized, controlled trials were identified through a comprehensive, systematic literature exploration, primarily utilizing the PubMed, EMBASE, Ovid, and Cochrane Library databases. The efficacy and safety outcomes consist of the proportion of patients reporting either 30% or 50% pain reduction and overall withdrawal or withdrawal due to adverse drug events, respectively. Effect estimates from Bayesian NMA were presented as odds ratio (OR) with 95% credible intervals (CrI). Heterogeneity and convergence were assessed by using I2 and deviation information criteria. The risk of bias was evaluated by using Pedro Scale. A total of 3,246 potentially relevant trials were identified and screened, finally 43 trials consisting of 7,877 randomized patients met the inclusion criteria. Statistically significant treatment difference for 50% pain reduction was reported for duloxetine vs. placebo (OR: 2.50; CrI: 1.62-3.91), mirogabalin vs. placebo (OR: 3.25; CrI: 1.16-9.35), pregabalin vs. placebo (OR: 2.33; CrI: 1.69-3.27), duloxetine vs. carbamazepine (OR: 3.37; CrI: 1.07-10.90), mirogabalin vs. carbamazepine (OR: 4.39; CrI: 1.01-19.63), mirogabalin vs. lamotrigine (OR: 4.05: CrI: 1.07-15.77), pregabalin vs. lamotrigine (OR: 2.90, CrI: 1.19-7.22) and pregabalin vs. nortriptyline (OR: 4.10, CrI: 1.13-5.28). Nortriptyline reported the highest possibility of achieving 30% and 50% pain reduction. Sodium valproate and benztropine reported the highest probability of total withdrawals and withdrawals due to adverse drug events, respectively. The different follow-up time of the included studies can result in the variation of intended results. Nortriptyline reported the advantage relative to other drugs in achieving 30% and 50% pain reduction from the baseline. Gabapentin reported a significance of 50% pain reduction relative to placebo.

ObjectiveTo compare the efficacy and safety of different anti-vascular endothelial growth factor (VEGF) agents combined with different delivery methods for neovascular glaucoma (NVG).DesignSystematic review and Bayesian network meta-analysis (NMA).Data sourcesPubMed,...

Comparative efficacy of exercise modalities on sleep architecture in adults with sleep disorders: a systematic review and network meta-analysis of randomized controlled trials.

Pediatric primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia and an increased risk of bleeding. Conventional therapies, while effective in some cases, are often limited by suboptimal response rates and significant adverse effects with prolonged use. Thrombopoietin receptor agonists (TPO-RAs), including recombinant human thrombopoietin (rhTPO), romiplostim, and eltrombopag, have emerged as promising therapeutic alternatives for pediatric ITP. However, a comprehensive comparison of their efficacy and safety profiles remains lacking. To conduct a systematic review and network meta-analysis to evaluate and compare the efficacy and safety of rhTPO, romiplostim, and eltrombopag in the treatment of pediatric ITP. A systematic literature search was performed across PubMed, Embase, Cochrane Library, and other relevant databases. Seven randomized controlled trials (RCTs) involving a total of 375 pediatric ITP patients were included. Direct meta-analysis and Bayesian network meta-analysis were employed to assess overall response rates (ORR) and the incidence of serious adverse events (SAEs). The Surface Under the Cumulative Ranking Curve (SUCRA) was utilized to rank the interventions based on their efficacy and safety. Direct meta-analysis demonstrated that romiplostim (OR = 17.57, 95% CI: 4.90-63.03), eltrombopag (OR = 5.34, 95% CI: 2.50-11.39), and rhTPO (OR = 5.32, 95% CI: 2.03-13.96) were all significantly more effective than placebo in achieving ORR (P < 0.001). In terms of SAEs, romiplostim was associated with a higher risk (OR = 3.79, 95% CI: 0.66-21.85), whereas eltrombopag (OR = 0.68, 95% CI: 0.23-2.03) and rhTPO (OR = 0.28, 95% CI: 0.01-7.17) exhibited more favorable safety profiles. Network meta-analysis ranked romiplostim (SUCRA = 0.96) as the most efficacious intervention, followed by eltrombopag (0.52) and rhTPO (0.52). For safety, rhTPO (SUCRA = 0.78) ranked highest, followed by eltrombopag (0.66), while romiplostim (0.12) was associated with the highest risk. Romiplostim exhibits superior efficacy in the management of pediatric ITP but necessitates vigilant monitoring for potential adverse effects, including bone marrow fibrosis. rhTPO, with its favorable safety profile, is particularly well-suited for acute bleeding scenarios. Eltrombopag offers a balanced combination of oral convenience and safety, making it an optimal choice for long-term therapy. Clinical decision-making should be guided by individual patient factors, including bleeding risk, treatment adherence, and drug accessibility. Future research should prioritize head-to-head comparative trials and long-term follow-up studies to further refine therapeutic strategies and optimize outcomes in pediatric ITP.