Draft synthesis: weight change after discontinuation of an… — submissions
The 16 submissions received, published in full with declared interests and secretariat responses.
§2Submissions and responses
16 submissions were received. Each is published in full below with its declared interest, the secretariat response and the disposition. The Institute publishes submissions it did not accept in the same form as those it did.
The document is unreadable without specialist training
The respondent notes that the review question — In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? — is answerable only if the contributing trials measured the same thing, and submits with that in view.
The respondent states that the draft is written for a reader who already understands certainty grading, and that the people most affected by the subject matter will not reach the assessment at all.
The respondent proposes a plain-language summary at the head of every document, written to the same standard of accuracy as the document itself and not as a promotional abstract.
The secretariat accepts this submission in part. A plain-language summary is added. The proposal that it replace the technical abstract is declined, because the abstract is the part of the document other assessors read and cite.
Every document now opens with a plain-language summary of not more than 150 words, placed above the technical abstract and carrying the same certainty language, so that the two cannot diverge.
An indirect comparison is presented without an assessment of transitivity
This submission concerns the draft review of In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn?. The respondent has conducted reviews on adjacent questions and the observation arises from that experience.
The draft compares two interventions through a common comparator. The respondent states that the trials contributing to each side differ in background therapy and in baseline severity, and that the resulting estimate assumes a similarity the draft does not test.
The respondent proposes that transitivity be assessed explicitly and reported before any indirect estimate is presented.
The secretariat accepts this submission. An indirect estimate presented without a transitivity assessment invites a reader to treat an assumption as a result.
Transitivity is now assessed against a stated list of effect modifiers and reported before any indirect estimate, and where the assessment fails the contrast is reported as unestimable with the reason rather than estimated with a caveat.
Regulatory assessment documents were not searched
Having read the draft synthesis on In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn?, the respondent puts one point to the committee.
The respondent states that regulatory assessment reports frequently contain analyses that never appear in journals, and that a search limited to bibliographic databases will miss them.
The respondent proposes that regulatory documents be searched for every review in the series.
The respondent has read submission 002 and asks that this submission be considered with it.
The secretariat accepts this submission in part. Regulatory assessment documents are searched. The proposal that they be treated as equivalent to a full study report is declined, because the level of detail varies and is often insufficient for risk-of-bias assessment.
Published regulatory assessment documents are now searched as a named source, are reported as a distinct evidence class in the included-studies table, and contribute to the assessment while being excluded from pooled estimates where risk of bias could not be assessed from the document.
Studies not published in English were excluded without assessment
The respondent read In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? in draft. The point applies to it and to the series generally.
The respondent states that a language restriction was applied at screening and that for some of the compounds in scope a substantial literature is published in other languages.
The respondent proposes that the restriction be removed and the review re-run.
The secretariat accepts this submission in part. The restriction is removed prospectively and the records already excluded on language grounds have been retrieved and screened on title and abstract in translation. The full re-run proposed is not undertaken, and the limitation is recorded rather than concealed.
Language restriction is removed from the protocol for the series, the records previously excluded on that ground are listed with their screening outcome, and the residual limitation is stated in the abstract of this review.
The search was limited by publication date and the limit is not justified
The respondent submits on the draft synthesis addressing In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn?. This submission concerns the methods rather than the conclusion, on the view that a conclusion is only as good as the search that produced it.
The search strategy carries a start date some years before the review. No reason is given. If the limit reflects the date of first synthesis of the compound it is defensible and should be said; if it reflects convenience it is a source of bias.
The respondent proposes that every date limit carry its justification in the search-strategy section.
The secretariat accepts the requirement to justify and declines to remove limits that are justified.
Every date limit in the series now carries its justification in the search-strategy section. Limits that could not be justified on re-examination have been removed and the affected searches re-run.
The review protocol is described but its registration record is not linked
The respondent has read the draft synthesis on In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? and makes one submission.
The respondent asks for the prospective registration record of the review protocol so that the registered outcomes can be compared with the reported ones.
The respondent states that without it the claim of prospective registration cannot be checked.
The secretariat accepts this submission in part. The protocol is published in full on the Institute site with its version history, which permits the comparison the respondent asks for. Where an external registration identifier is not held by the Institute, the review says so rather than supplying one.
Each synthesis now links its own protocol with the version in force at screening, and states explicitly where an external registration identifier is not held, so that the absence is a recorded fact.
Risk-of-bias judgements are reported as an overall rating without the domains
The respondent’s comment on the draft review of In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? arises from comparing the included set against the respondent’s own knowledge of the field.
The draft reports a single overall risk-of-bias judgement per study. The respondent states that the overall judgement conceals which domain drove it, and that a reader assessing whether the concern applies to their question needs the domain.
The respondent proposes a domain-level table with the supporting quotation for each judgement.
This submission is made in the same spirit as submission 004 and on a different aspect of the draft.
The secretariat accepts this submission. The overall judgement is a summary of the domains and publishing only the summary makes it uncheckable.
Risk of bias is now reported at domain level for every included study, with the text on which each judgement was based quoted and referenced, and the overall judgement derived from the domains rather than asserted alongside them.
Baseline imbalance in a small contributing trial is not remarked on
The respondent submits on In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn?, on a matter that is not specific to this draft but is visible in it.
The respondent identifies a small contributing trial with a baseline difference in the outcome variable, and states that the difference is large enough to account for a share of the reported effect.
The respondent asks that the trial be excluded or that the imbalance be addressed.
The respondent’s submission overlaps with submission 003 and was prepared without sight of it.
The secretariat notes this submission. The imbalance is recorded in the risk-of-bias assessment for that trial, in the domain concerning the randomisation process, where the respondent may not have looked.
No amendment arises. The judgement and the supporting figures are already reported at domain level for that study, and a sensitivity analysis omitting it is reported in the results, which does not change the direction of the estimate.
Absence of evidence is presented in a form a reader will take as negative evidence
This submission addresses the draft synthesis on In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? from the standpoint of a reader who will use the summary and not the appendices.
Where the Institute has identified no study, the draft states that no evidence was found. In several places that sentence sits immediately after a paragraph describing an adverse outcome, and the juxtaposition invites the reading that the compound was studied and found wanting.
The respondent proposes a standing formulation, used identically wherever the situation arises, distinguishing an outcome that was studied and not demonstrated from an outcome that has not been studied at all.
This point is adjacent to the one made in submission 008 and the respondent puts it in a form the secretariat can act on.
The secretariat accepts this submission. The two states are different, they support different decisions, and the draft rendered them in language a reader could not reliably separate.
A standing formulation has been adopted and is applied wherever an evidence gap is recorded, distinguishing an outcome assessed and not demonstrated from an outcome not assessed. The formulation is identical at every occurrence so that it can be recognised at a glance.
Two included studies do not meet the registered eligibility criteria
The respondent has read In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? in draft and makes a single submission.
The respondent identifies two studies in the included set whose duration falls below the minimum stated in the protocol, and one excluded study that appears to meet every criterion.
The respondent proposes that the three be reassessed and that the outcome of the reassessment be recorded whichever way it goes.
The secretariat accepts this submission in part. On reassessment, one of the two included studies does fall below the minimum duration and has been removed. The second reports a duration that met the criterion in the protocol version registered at the time. The excluded study was excluded for a reason not clearly recorded, which was a documentation failure.
One study has been removed from the included set and the estimate recomputed, the exclusion reason for the third study has been corrected in the excluded-studies table, and the screening decisions are now recorded against the protocol version in force at the time of screening.
The conclusion is stated more strongly than the certainty rating supports
This is a submission on In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn?.
The draft rates the anchor outcome at low certainty and then states the finding in the conclusion without qualification. The respondent states that the two sentences cannot both be true as written.
The respondent proposes that conclusion language be tied mechanically to the certainty rating, so that a low rating cannot produce an unqualified claim.
The respondent has read submission 005 with interest and adds one observation the secretariat may find useful.
The secretariat accepts this submission. The mismatch is the failure mode the certainty framework exists to prevent.
Conclusion wording is now drawn from a fixed set of formulations tied to the certainty rating, so that a low certainty rating produces a statement that the evidence may suggest an effect and that the estimate is likely to change with further research.
A sponsor trial meeting the eligibility criteria was excluded
The draft review of In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? was read against its registered protocol.
The submission is made on behalf of the sponsor. It identifies a completed trial of the sponsor's compound that meets the stated eligibility criteria and does not appear in the included set, and supplies the trial report and the registry record.
The sponsor asks that the trial be included and the estimate recomputed. No view is expressed on the direction the recomputation should take.
The secretariat accepts this submission in part. The trial does meet the criteria and has been included. The recomputed estimate is materially unchanged, which the response states explicitly so that the outcome of the correction is on the record.
The trial is added to the included set, the estimate and the certainty rating have been recomputed, and the screening record now states why the trial was missed, which was a database indexing gap rather than a screening judgement. The submission is identified as an industry submission.
Doses differing several-fold are pooled without examining dose-response
This submission concerns In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? and a convention used across the Institute’s output.
Contributing trials administer doses that differ by a factor of several. The draft pools them and reports one estimate. The respondent states that where a dose-response relationship exists the pooled figure corresponds to no dose that anyone receives.
The respondent proposes that estimates be reported by dose and that dose-response be examined where the data allow.
The secretariat accepts this submission. A pooled estimate across doses is an estimate for an average dose that no protocol specifies.
Estimates are now reported by dose group, a dose-response examination is reported where three or more dose levels contribute, and the pooled across-dose estimate is removed rather than retained alongside.
The review question is drawn too broadly to be answerable
This is a submission on the draft review of In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn?, made from a statistical standpoint.
The respondent states that the population as registered spans groups in which the intervention would be expected to behave differently, and that a single estimate across them is uninformative.
The respondent proposes that the question be split and the review re-registered.
This submission is made in the same spirit as submission 002 and on a different aspect of the draft.
The secretariat does not accept this submission. The breadth was registered before screening, the pre-specified subgroups address the variation the respondent identifies, and re-registering after the results are known would convert a pre-specified analysis into a post hoc one.
The question stands as registered. The point is recorded in the limitations, and the assessment committee has noted it for the protocol of the next version of this review, which will be registered before the search is run. The submission remains published in full.
Two factual descriptions of the sponsor's programme are inaccurate
Having read the draft under consultation, which concerns In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn?, the respondent submits as follows.
The submission is made on behalf of the marketing-authorisation holder and is confined to two matters of fact. The draft describes a trial as terminated where the sponsor closed it at a pre-specified interim analysis, and gives a dose in a unit that does not match the approved labelling.
Supporting documentation, comprising the published trial report and the current summary of product characteristics, accompanied the submission. No view is expressed on the certainty ratings, which the sponsor considers a matter for the assessment committee.
The secretariat accepts this submission. Both points are matters of fact, both were checkable against documents the Institute holds, and both were wrong in the draft.
The trial status now reads as completed at a pre-specified interim analysis, with the analysis identified, and the dose is stated in the unit used in the approved labelling. The submission is identified as an industry submission on its face in accordance with the conflicts policy.
The document should not describe uses outside the approved indication
The respondent read the draft review of In adults who have lost weight during treatment with an incretin receptor agonist, what happens to body weight after treatment is withdrawn? and has confined this submission to a single matter.
The submission is made on behalf of a marketing-authorisation holder. It states that the draft describes uses of the compound that fall outside the approved indication, that such uses are not supported by the sponsor, and that describing them may be read as legitimising them.
The sponsor asks that the sections concerned be removed, or in the alternative that they carry a prominent statement that the sponsor does not support such use.
The secretariat does not accept this submission. The Institute records what is supplied and what is used, because a reader encountering a compound outside a regulated route is the reader most in need of an assessment of the evidence for it.
The sections remain. Every such section already states the regulatory status of the use described and states that the evidence for it is assessed separately from the evidence for the approved indication. The submission is published in full and identified as an industry submission.
References cited on this page
References are numbered in order of first citation in this document. Each superscript in the text links to its entry below.
- International Organization for Standardization. ISO/IEC 17025:2017 General Requirements for the Competence of Testing and Calibration Laboratories. ISO/IEC Standard 2017;3rd edition. identifier not held by the Institute
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