Bjermer 1995.

Methods	RCT of mitoxantrone versus mepacrine via an intercostal drain (Sweden ‐ number of centres not specified)
Participants	Cytologically proven, symptomatic MPE with an expected survival of greater than three months (Karnofsky Performance Score > 60). Excluded if cytotoxic chemotherapy in the preceding month All cell types included 30 participants randomised
Interventions	Both groups had a 12‐14 Fr chest tube inserted and effusion drained. Pleurodesis agent was given through the chest tube and patient's position changed for two hours after administration Group 1: 1 dose of intrapleural mitoxantrone 30 mg in 50 ml N saline was given; the drain was closed for 48 hours and removed after the 'pleural cavity was emptied' Group 2: 2 doses of intrapleural mepacrine chloride 200 mg in 20 ml N saline were given on consecutive days and the drain removed when < 150 ml fluid production/day
Outcomes	Pleural fluid re‐accumulation at 4 and 12 weeks (defined as 'Complete response' (CR), 'Partial response' (PR) (if recurrence of pleural fluid but thoracocentesis not considered to be indicated) or 'Progressive disease'. Side effects/toxicity (visual analogue scale pain and fever scores) Symptom questionnaires (participant grades symptom on a numeric scale for four key symptoms‐ pain, shortness of breath, nausea and tiredness) Pharmacokinetics of mitoxantrone
Notes	People with trapped lung not excluded from the study CR and PR counted as pleurodesis success for analysis Included in network meta‐analysis for pleurodesis efficacy and mortality.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not specified and unable to find contact details for study authors
Allocation concealment (selection bias)	Unclear risk	Not specified and unable to find contact details for study authors
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Study personnel not blinded as drugs are of different colours. However, participants were blinded to treatment allocation
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Participants blind to treatment allocation, therefore fever, pain and symptom scores unbiased. "Radiological evaluation was made by an independent radiologist'
Incomplete outcome data (attrition bias) All outcomes	Low risk	One participant in each study arm did not receive treatment due to "unexpected medical emergencies", therefore deemed non‐evaluable. Follow‐up data clearly documented for the remaining patients
Selective reporting (reporting bias)	Low risk	All pre‐specified outcomes reported
Other bias	Low risk	Drain suction use was imbalanced between the treatment arms (10/14 received suction in mepacrine group vs 1/14 in mitoxantrone group)