Collagenase: What We May Never Know (A Discussion)
Whilst randomised trials can provide robust and clinically essential data, they cannot answer all questions. There are certain aspects about collagenase which we will have to deduce and cannot prove. Some cords are “twigs” and some are “logs”; it is unlikely that one treatment will be equally suitable for both. Suitable outcome measures are not established. There is no established broadly agreed scoring scheme for Dupuytren disease. One cannot, for example, balance a lower recurrence rate with surgery with the prompter recovery from PNF or collagenase, nor the higher complication rate with surgery against the lower cost of collagenase nor the very cheap cost of needle fasciotomy. A randomised trial requires equipoise from both the investigators and the subjects; the preconceptions of doctors and patients may compromise equipoise and introduce bias into recruitment. Proper comparative trials cost a vast amount of money so that sourcing adequate funding may be a challenge, particularly since long-term outcomes are required particularly to compare recurrence.
KeywordsCollagenase Side effects Research Heterogeneity of disease Outcome measures Randomised controlled trial Efficacy Percutaneous needle fasciotomy Fasciectomy
Conflict of Interest
The author has been a paid consultant to Pfizer and SOBI (European distributors of Xiapex) and Actelion (Australian distributor of Xiaflex.) He has received travel support, accommodation and honoraria on several occasions in relation to advising on the drug and giving presentations to learned societies and other groups. He has not been paid or received any other support in relation to the International Dupuytren Symposium or to this chapter.
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