Long-term effect of inhaled budesonide in mild and moderate chronic obstructive pulmonary disease: a randomised controlled trial

Advances in the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible airflow limitation with extreme economic and social burden. It is estimated that over the next two decades, it will become the 5(th) most prevalent disease and the 3(rd) most common cause of death in the world. A better understanding of the pathogenesis of airway inflammation and alveolar destruction allows for the development of new therapeutic targets. Tobacco smoking is the most important risk factor in the development of COPD, thus making smoking cessation of the outermost importance. This article provides a critical review of present therapy for COPD. In addition to conventional treatment (bronchodilators, corticosteroids and antibiotics) and smoking cessation therapies, novel approaches with potential benefit are discussed.

Effectiveness of inhaled corticosteroids in chronic obstructive pulmonary disease: immortal time bias in observational studies

Recent large-scale cohort studies that reported an important reduction in mortality and chronic obstructive pulmonary disease (COPD) morbidity with inhaled corticosteroids may be biased. We used a population-based cohort of Saskatchewan residents 55 years of age or over, first hospitalized for COPD during 1990 to 1997, to study this potential bias. These 979 subjects were followed for a year from discharge until their first readmission for COPD or death (389 subjects). Inhaled corticosteroid exposure was measured as any dispensing within 90 days after discharge. Cox's proportional hazards model was used to compare the time-fixed analysis employed in the recent studies with the alternative time-dependent analysis. The time-fixed adjusted rate ratio was 0.69 (95% CI: 0.55-0.86) for inhaled corticosteroid use within 90 days, whereas the time-dependent rate ratio was 1.00 (95% CI: 0.79-1.26). With the time-fixed analysis, the rate ratios were affected by the length of the exposure period, decreasing from 0.98 for a 15-day exposure period to 0.51 for 365 days, but remained stable between 1.06 and 0.94 with the time-dependent analysis. Inhaled corticosteroid use after hospitalization for COPD was not found to reduce mortality and morbidity. Although observational studies can be valuable, the recent reports of reductions in mortality and morbidity with inhaled corticosteroids are biased by their inappropriate allocation of exposure and analysis of immortal time.

Potential new drugs for therapy of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is a major health problem with cigarette smoking as its major risk factor. Current therapies are directed against the symptoms (e.g., breathlessness and mucus production) or the chronic airway inflammation. However, the excessive annual decline in lung function and the airway inflammation have not yet been shown to be improved by these strategies. New potential drug therapies are directed against specific components of the inflammation. Novel drugs have been developed for treatment of inflammatory diseases including chronic obstructive pulmonary disease in order to antagonise cytokines and chemokines such as TNF-alpha, CXC chemokine ligand 8 (IL-8) or CC chemokine ligand 2 (monocyte chemoattractant protein 1) that orchestrate the inflammatory process. Some of these drugs are shown to be effective in patients with other chronic inflammatory diseases but still have to prove their efficacy in the treatment of chronic obstructive pulmonary disease.

Management of the symptomatic patient

Chronic obstructive pulmonary disease (COPD) is both preventable and treatable. There has been a significant reduction in premature morbidity and mortality from heart disease and stroke, the number 1 and 3 killers in the United States, respectively, largely because of efforts to increase both clinician and public awareness of these diseases. Early and aggressive management of COPD has not yet reached the same level. Primary care professionals are in the forefront in the early detection, prevention, and treatment of this serious national health problem.

New concepts in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability but has only recently been explored from a cellular and molecular perspective. In COPD, chronic inflammation leads to fixed narrowing of small airways and alveolar wall destruction (emphysema). This is characterized by increased numbers of alveolar macrophages, neutrophils, and cytotoxic T lymphocytes, and the release of multiple inflammatory mediators (lipids, chemokines, cytokines, growth factors). There is also a high level of oxidative stress, which may amplify this inflammation. There is increased elastolysis and probable involvement of matrix metalloproteinases. The inflammation and proteolysis in COPD is an amplification of the normal inflammatory response to cigarette smoke. Unlike asthma, this inflammation appears to be resistant to corticosteroids, prompting a search for novel anti-inflammatory therapies that may prevent the relentless progression of the disease.

Inhaled corticosteroids in chronic obstructive pulmonary disease: new trials and old practices

The practice of using inhaled steroids (ICS) in chronic obstructive pulmonary disease (COPD) is common but controversial. Four large randomized controlled trials provide an objective assessment of this practice. An examination of the design of these studies is useful to explaining some of the differences between their results but may also help to appropriately integrate the findings of these studies into clinical practice. All studies agree that the early introduction of the inhaled corticosteroids (ICS) does not appear to affect the rate of decline in FEV1. Thus, the routine prescription of these agents to asymptomatic patients with well-preserved lung function is not indicated. However, more selective use of ICS in patients with moderately severe disease (FEV1 < 50% predicted) may produce clinical benefit as measured by an increase in FEV1, reduced symptoms and fewer exacerbations. The effectiveness of ICS in patients with severe disease (FEV < 800 mL, or chronic respiratory failure) has not been studied due to practical difficulties of enrolling and maintaining such patients in clinical trials. Similarly patients with evidence of chronic bronchitis and emphysema who demonstrate high degrees of reversibility (>10% predicted FEV1) are usually excluded from both COPD and asthma trials, and the effectiveness of ICS in this population is also not known. Neither responsiveness to a single dose of beta(2)-agonist nor to a 14-day trial of systemic steroids has been shown to be a reliable predictor of response to ICS. For individual patients with moderate or severe symptomatic COPD, an 8-week therapeutic trial with ICS may be needed to assess clinical benefit.

Effects of inhaled corticosteroids with different lung deposition on exhaled hydrogen peroxide in stable COPD patients

BACKGROUND

The effects of inhaled corticosteroids (ICS) on markers of oxidative stress in patients with stable COPD are unclear.

OBJECTIVES

The aim was to investigate the effect of ICS on exhaled H(2)O(2) in stable COPD patients and to compare ICS with different lung deposition.

METHODS

Forty-one stable patients with moderate COPD (FEV(1) approximately 60% predicted) were randomized to sequence 1; first HFA-134a beclomethasone dipropionate (HFA-BDP, an ICS with more peripheral deposition) 400 microg b.i.d., then fluticasone propionate (FP, an ICS with more central deposition) 375 microg b.i.d. (n = 20) or sequence 2; first FP, then HFA-BDP (n = 21). Both 4-week treatment periods were preceded by a 4-week washout period. After each period, the concentration of H(2)O(2) in exhaled breath condensate was measured.

RESULTS

The H(2)O(2) concentration decreased significantly after the first treatment period in both sequence 1 and 2 (p < 0.05, p = 0.01, respectively). In neither sequence was there a return to baseline values after the second washout, indicating a carry-over effect. The concentrations remained low in both sequences during the second treatment period.

CONCLUSIONS

Both ICS appeared to reduce exhaled H(2)O(2) in stable COPD patients. However, this study showed no difference between ICS with different deposition patterns, which in part may be due to the carry-over effect.

[Drug treatment of chronic obstructive pulmonary disease on two levels of patient care: degree of compliance with recommended protocols]

OBJECTIVE

The aims of this study were to identify the drug treatment protocols applied by primary care physicians or pneumologists for patients with stable chronic obstructive pulmonary disease (COPD) in Spain, to determine the agreement between prescription practices and current recommendations and to assess differences between the two levels of patient care.

PATIENTS AND METHODS

The study was observational, descriptive and multicenter. A stratified random sample of patients treated by family physicians or pneumologists was taken for every region in Spain.

RESULTS

Five hundred sixty-eight (63.2%) of the 898 subjects fulfilled COPD diagnostic criteria; 100 were treated by primary care physicians and 460 by pneumologists. In 8 cases the caregiver was unknown. Obstruction was mild-to-moderate in 144 cases and severe in 416. The drugs most commonly prescribed were ipratropium bromide (77.8%), inhaled short-acting beta(2) agonists (65.8%), inhaled corticosteroids (61.0%), long-acting beta(2) agonists (46.4%) and theophyllines (41.3%). Primary care physicians prescribed inhaled short-acting beta 2-agonists most often, whereas pneumologists prescribed anticholinergics most often. In the primary care setting, no differences in treatment protocols were observed based on severity of COPD, degree of dyspnea or quality of life. More consistent differences were seen in treatment by pneumologists. In both settings, prescription was more frequently given when COPD was severe. The most commonly prescribed inhalation device was the Turbuhaler in primary care and the pressurized canister in pneumology.

CONCLUSIONS

Treatments prescribed for COPD patients do not follow current guidelines strictly, particularly in the primary care setting. Different prescription protocols are used at the different levels of patient care.

Treatment of chronic obstructive pulmonary disease in older patients: a practical guide

Chronic obstructive pulmonary disease (COPD) is a common disability, largely encountered in the elderly population, in whom it causes significant morbidity and mortality. The general perception of health professionals is that COPD is often a self-inflicted disorder affecting the more socio-economically disadvantaged segment of the population with significant comorbidity. COPD is the least funded in terms of research in relation to illness burden compared with other chronic diseases. However, recently published guidelines of both the British Thoracic Society and the Global Initiative for Chronic Obstructive Lung Disease have highlighted best management strategies both of chronic symptoms and acute exacerbations in this patient group. The chronic management of COPD should, like asthma, involve a stepwise approach with smoking cessation being pivotal for all severities of COPD, regardless of patient age. The mainstay of therapeutic treatment remains regular bronchodilators, both beta(2)-adrenoreceptor agonists and anticholinergic agents. Current evidence suggests that long-acting beta(2)-adrenoreceptor agonists such as salmeterol and the new long-acting anticholinergic agent tiotropium bromide are more efficacious than their shorter acting equivalents such as salbutamol and ipratropium bromide in terms of bronchodilation, improved well-being and a reduction in acute exacerbation rates. Additionally since they are taken once or twice daily compliance should be improved. The role of long-term inhaled corticosteroids in the chronic management of COPD is contentious. Only those patients with COPD who have been shown to respond to a formal corticosteroid trial, preferably with a 2-week course of oral corticosteroid, should receive long-term inhaled corticosteroids. In the management of acute exacerbations in acidotic patients nasal ventilation is the treatment of choice in addition to conventional treatment with bronchodilators and oral corticosteroids. Antibacterials need not be prescribed universally in all exacerbations of COPD. Pulmonary rehabilitation classes either individually or in groups have been shown to be beneficial in the management of patients with COPD and their use in secondary care is to be encouraged. Most treatment modalities do not improve pulmonary function in patients with severe COPD. Therefore, pulmonary function including spirometry should be used to make the diagnosis of COPD but not as a monitor of efficacy of treatment. Assessment of severity of COPD and improvement with treatment modalities is best done with dynamic exercise testing such as 6-minute walk tests and incremental shuttle walk tests or with the administration of disease-specific physical disability and quality-of-life questionnaires. Most COPD research does not specifically target the older COPD patients and these patients may merit special consideration for their optimum assessment and management.

Approaches to slowing the progression of COPD

Chronic obstructive pulmonary disease (COPD) is a major health problem across the world and its medical, societal and economic impacts continue to grow. There are several hypotheses regarding the pathogenesis of COPD and important new information on airway inflammation, oxidative stress and proteolysis in the lungs that are important for the development of effective treatments. The differences in susceptibility to COPD among cigarette smokers and the common familial risk of developing disease point to important genetic influences. The identification of candidate gene loci and various gene polymorphisms have improved our understanding of the mechanisms by which genetic factors predispose for COPD. The beneficial effects of smoking cessation in slowing the decline in lung function and the progression of disease have been clearly established. Whether other factors such as mucus hypersecretion, respiratory infections and airway hyperreactivity contribute to disease progression independent of cigarette smoking is still being debated. There is new interest in dietary strategies to prevent or control COPD and preliminary information suggesting the usefulness of diets favoring antioxidant-rich foods. On the other hand several large, long-term, randomized, controlled clinical trials have failed to show a beneficial effect of either anticholinergics or corticosteroids in slowing the rate of decline in lung function in COPD. Corticosteroid treatment, however, appears to reduce the frequency of COPD exacerbations and there is some suggestion that it may also reduce the risk of death in patients with severe COPD.

Chronic obstructive pulmonary disease . 7: Management of COPD

A review of the management of COPD is presented, with particular emphasis on the effect on the approach to management of new information which has become available in the 5 years since the BTS guidelines on COPD were published. A major problem is the effective implementation of what is already known, and allocation of the resources necessary to make this available to all who might benefit.

Cost-effectiveness of fluticasone propionate in the treatment of chronic obstructive pulmonary disease: a double-blind randomized, placebo-controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a debilitating disease and places a large financial burden on health-care systems and society. We prospectively evaluated the cost-effectiveness offluticasone propionate (FP) treatment in patients with moderate-to-severe COPD, who were symptomatic on regular bronchodilator therapy.

METHODS

An economic analysis was performed in a 6-month, randomized, double-blind clinical trial comparing FP 1,000 microg/day with placebo in 281 patients aged 45-79 years with symptomatic moderate-to-severe COPD. Data on clinical efficacy, health-care resource use and productivity loss associated with the management of COPD were prospectively collected. The main outcome measures were the incremental cost-effectiveness of achieving a > or = 10% improvement in FEV1 and of remaining exacerbation-free throughout the study. The economic evaluation was costed from the perspective of the NHS (direct costs) and of society (direct and indirect costs).

RESULTS

FP was significantly more effective than placebo in terms of the proportions of patients demonstrating a > or = 10% improvement in FEV1 (32 vs. 19%; P = 0.02) and remaining free of moderate/severe exacerbations (75 vs. 63%; P = 0.02). The difference between the groups in total costs was not significantly different. Incremental cost-effectiveness analyses showed that the additional clinical benefits of FP relativeto placebo, in terms of a > or = 10% improvement in FEV1 or an increased number of patients free of moderate/severe exacerbations, were achieved at minimal additional costs from an NHS perspective (additional 0.25 pounds per day for bath) or at a net saving from a societal perspective. Sensitivity analysis showed that these results were robust to changes in the underlying assumptions.

CONCLUSIONS

Treatment with FP was associated with statistically significant clinical benefits in patients with moderate-to-severe COPD currently symptomatic on regular bronchodilator therapy. As the differences in direct and total costs compared with placebo were small and non-significant, this treatment can be considered cost-effective in this patient population.

Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial

BACKGROUND

Inhaled long-acting beta2 agonists improve lung function and health status in symptomatic chronic obstructive pulmonary disease (COPD), whereas inhaled corticosteroids reduce the frequency of acute episodes of symptom exacerbation and delay deterioration in health status. We postulated that a combination of these treatments would be better than each component used alone.

METHODS

1465 patients with COPD were recruited from outpatient departments in 25 countries. They were treated in a randomised, double-blind, parallel-group, placebo-controlled study with either 50 microg salmeterol twice daily (n=372), 500 microg fluticasone twice daily (n=374), 50 microg salmeterol and 500 microg fluticasone twice daily (n=358), or placebo (n=361) for 12 months. The primary outcome was the pretreatment forced expiratory volume in 1s (FEV1) after 12 months treatment' and after patients had abstained from all bronchodilators for at least 6h and from study medication for at least 12h. Secondary outcomes were other lung function measurements, symptoms and rescue treatment use, the number of exacerbations, patient withdrawals, and disease-specific health status. We assessed adverse events, serum cortisol concentrations, skin bruising, and electrocardiograms. Analysis was as predefined in the study protocol.

FINDINGS

All active treatments improved lung function, symptoms, and health status and reduced use of rescue medication and frequency of exacerbations. Combination therapy improved pretreatment FEV1 significantly more than did placebo (treatment difference 133 mL, 95% CI 105-161, p<0.0001), salmeterol (73 mL, 46-101, p<0.0001), or fluticasone alone (95 mL, 67-122, p<0.0001). Combination treatment produced a clinically significant improvement in health status and the greatest reduction in daily symptoms. All treatments were well tolerated with no difference in the frequency of adverse events, bruising, or clinically significant falls in serum cortisol concentration.

INTERPRETATION

Because inhaled long-acting beta2 agonists and corticosteroid combination treatment produces better control of symptoms and lung function, with no greater risk of side-effects than that with use of either component alone, this combination treatment should be considered for patients with COPD.

Inhaled Corticosteroids in the Long-Term Management of Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a major problem in the elderly population, with approximately 10% of the population affected. Since COPD is an inflammatory disorder of the pulmonary system, corticosteroids might be expected to improve clinical outcomes of the disease. Data from large, well designed randomised clinical trials in which approximately one third of patients were > or =65 years of age indicate that inhaled corticosteroids do not modify the natural history of COPD, as measured by the rate of decline in forced expiratory volume in 1 second (FEV1). However, these same studies also suggest that corticosteroids reduce the frequency of clinical exacerbations by nearly a third (compared with placebo). This beneficial effect is particularly pronounced among those with an FEV1 less than 50% of the predicted value. Withdrawal of inhaled corticosteroids, on the other hand, leads to increased symptoms and elevates the risk of exacerbations by 50% above baseline levels. Patients' health-related quality of life is also improved by the use of inhaled corticosteroids. It is clear that inhaled corticosteroids elevate the risk of thrush, dysphonia and skin bruising by 2-fold compared with placebo. In addition, the sum of evidence suggests a modest deleterious effect for inhaled corticosteroids on bone mineral density, especially for formulations that have an increased rate of systemic absorption. However, the clinical evidence of this observation is uncertain. The effect of inhaled corticosteroids on fracture risk is controversial with some observational studies suggesting a possible association. Whether inhaled corticosteroids increase the risk of ophthalmic complications (cataracts and glaucoma) is also uncertain. In conclusion, the current evidence indicates that inhaled corticosteroid therapy produces short- and long-term clinical benefits in COPD patients with moderate-to-severe disease and should be used as adjunctive therapy for elderly patients with COPD who experience frequent exacerbations or have moderately reduced lung function.

Therapy of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is one of the commonest causes of morbidity and mortality in the world, and is increasing in prevalence. Current therapies are not very effective, and no current treatment prevents the relentless progression of airflow limitation that characterizes this disease. Smoking cessation is the only strategy that reduces this decline in lung function, and although bupropion is the most effective aid to quitting, more effective treatments of nicotine addiction are needed. The mainstay of treatment is bronchodilators for symptom relief, and inhaled anticholinergics and beta(2)-agonists are useful by reducing hyperinflation of the lungs. A new once-daily inhaled anticholinergic is the most effective bronchodilator, but long-acting inhaled beta(2)-agonists are also useful. Theophylline is used as an additional bronchodilator in more severe patients, and may have some anti-inflammatory action. In contrast, inhaled corticosteroids are poorly effective and do not reduce disease progression, although recent studies with combination inhalers (corticosteroid + long-acting beta(2)-agonist) have shown better effects. Long-term oxygen therapy is needed by patients with pulmonary hypertension and right heart failure. There is a pressing need to develop new classes of therapy, and several new drugs are current in development, including interleukin-8 antagonists, phosphodiesterase-4 inhibitors, protease inhibitors, and antioxidants.

Chronic obstructive pulmonary disease. 5: systemic effects of COPD

The role of body cell mass wasting, muscle wasting, and changes in muscle metabolism in the pathogenesis of chronic obstructive pulmonary disease is reviewed.

Longitudinal changes in airflow limitation and airway hyperresponsiveness in patients with stable asthma

BACKGROUND

There are few long-term studies of the effects of treatment on the natural course of asthma.

OBJECTIVE

To investigate the longitudinal changes in airflow limitation and airway hyperresponsiveness (AHR) in asthma.

METHODS

We recruited 81 outpatients (never smokers) with stable asthma from the Kyoto University Hospital. They were evaluated for pulmonary function and AHR, expressed by forced expiratory volume in 1 second (FEV1) and the provocation dose that caused a 20% fall in FEV1 (PD20-FEV1), respectively, at entry and every 6 months over 3 years. We used random effects models to estimate the slopes of these changes, and then evaluated the relationship between these changes and their predictive factors.

RESULTS

Using random effects models, the percentage of the predicted FEV1 (%FEV1) declined significantly but slightly at a mean rate of 0.5%/year (P = 0.002; 95% confidence interval, 0.3 to 0.8). The mean decline rate of FEV1 was 34 mL/year. However, Log(PD20-FEV1) showed significant improvement at a mean rate of 0.088 cumulative units/year (P < 0.001; 95% confidence interval, 0.053 to 0.122). Multiple regression analysis showed that the baseline values of %FEV1 and Log(PD20-FEV1) were the most significant predictive factors for their subsequent changes, respectively.

CONCLUSIONS

In stable asthmatic patients treated according to international guidelines, airflow limitation progressed at a nearly normal rate over 3 years. However, AHR continued to improve despite its ceiling effects. Multiple regression analysis revealed a significant negative relationship between the initial values and the subsequent changes in airflow limitation and AHR, respectively.

Effect of discontinuation of inhaled corticosteroids in patients with chronic obstructive pulmonary disease: the COPE study

The aim of this double-blind single center study (the COPE study) was to investigate the effect of discontinuation of the inhaled corticosteroid fluticasone propionate (FP) on exacerbations and health-related quality of life in patients with chronic obstructive pulmonary disease. After 4 months of treatment with FP (1,000 microg/day), 244 patients were randomized to either continue FP or to receive placebo for 6 months: 123 patients continued FP (FP group), and 121 received placebo (placebo group). In the FP group, 58 (47%) patients developed at least one exacerbation compared with 69 (57%) in the placebo group. The hazard ratio of a first exacerbation in the placebo group compared with the FP group was 1.5 (95% confidence interval [CI] 1.1-2.1). In the placebo group 26 patients (21.5%) experienced rapid recurrent exacerbations and were subsequently unblinded and prescribed FP compared with 6 patients (4.9%) in the FP group (relative risk = 4.4; 95% CI 1.9-10.3). Over a 6-month period, a significant difference in favor of the FP group was observed in the total score (+2.48 95% CI 0.37-4.58), activity domain (+4.64 95% CI 1.60-7.68), and symptom domain (+4.58 95% CI 1.05-8.10) of the St. George's Respiratory Questionnaire. This study indicates that discontinuation of FP in patients with chronic obstructive pulmonary disease is associated with a more rapid onset and higher recurrence-risk of exacerbations and a significant deterioration in aspects of Health-Related Quality of Life.

Effects of fluticasone propionate in COPD patients with bronchial hyperresponsiveness

BACKGROUND

Treatment of chronic obstructive pulmonary disease (COPD) with inhaled corticosteroids does not appear to be as effective as similar treatment of asthma. It seems that only certain subgroups of patients with COPD benefit from steroid treatment. A study was undertaken to examine whether inhaled fluticasone propionate (FP) had an effect on lung function and on indices of inflammation in a subgroup of COPD patients with bronchial hyperresponsiveness (BHR).

METHODS

Twenty three patients with COPD were studied. Patients had to be persistent current smokers between 40 and 70 years of age. Non-specific BHR was defined as a PC(20) for histamine of <or=8 mg/ml. Patients received either 2 x 500 microg FP or placebo for 6 months. Expiratory volumes were measured at monthly visits, BHR was determined at the start of the study and after 3 and 6 months, and bronchial biopsy specimens were taken at the start and after 6 months of treatment. Biopsy specimens from asymptomatic smokers served as controls.

RESULTS

In contrast to asthma, indices of BHR were not significantly influenced by treatment with FP. Forced expiratory volume in 1 second (FEV(1)) showed a steep decline in the placebo group but remained stable in patients treated with FP. FEV(1)/FVC, and maximal expiratory flows at 50% and 25% FVC (MEF(50), MEF(25)) were significantly increased in the FP treated patients compared with the placebo group. Biopsy specimens were analysed for the presence of CD3+, CD4+, CD8+, MBP+, CD15+, CD68+, CD1a, and tryptase cells. FP treatment resulted in marginal reductions in these indices of inflammation.

CONCLUSION

In patients with COPD and BHR, FP has a positive effect on indices of lung function compared with placebo. Bronchial inflammation analysed in bronchial biopsy specimens is only marginally reduced.

Early life factors contribute to the decrease in lung function between ages 18 and 40: the Coronary Artery Risk Development in Young Adults study

Early life factors may influence pulmonary function. We measured forced expiratory volume in 1 second (FEV(1)) in 1985-1986 and 2, 5, and 10 years later in approximately 4,000 black and white men and women initially aged 18-30 years. We estimated the age pattern of FEV(1) according to family smoking status, early diagnosis of asthma, early smoking initiation, adult asthma, and cigarette smoking. FEV(1) followed a quadratic pattern from age of peak through age 40. The pattern varied by race and sex. Early smoking initiation was associated with a faster decrease in FEV(1). Smoking by family members was related to early life asthma and may have contributed to faster FEV(1) decrease by encouraging behaviors such as heavier smoking or earlier smoking initiation. Prevalence of smoking was 28% when no family member smoked, compared with 59% when four or more members smoked. The FEV(1) decline was 8.5% in never-smokers without asthma; 10.1% in nonsmoking individuals diagnosed with asthma; and 11.1% in baseline smokers who smoked 15 or more cigarettes per day. The combination of asthma and heavier smoking was synergistic (17.8% decline). This study delineates an increased rate of decline in those with asthma or in those who smoke cigarettes and implicates early life exposures as contributing to the faster rate of FEV(1) decline.

Neutrophil elastase inhibitors as treatment for COPD

Chronic obstructive pulmonary disease, characterised by a slowly progressive, irreversible airways limitation, is a major worldwide cause of chronic morbidity and mortality. The imbalance between human neutrophil elastase and endogenous antiproteases may cause excess human neutrophil elastase in pulmonary tissues, which may be considered a major pathogenic factor in chronic obstructive pulmonary disease. Great effort has been devoted to finding a method to restore the balance, resulting in the discovery of potent two-typed small-molecular-weight human neutrophil elastase inhibitors. In the application of chronic obstructive pulmonary disease therapy, the human neutrophil elastase inhibitors mainly focused upon include ONO-5046, MR-889, L-694,458, CE-1037, GW-311616 and TEI-8362 as the acyl-enzyme inhibitors; and ONO-6818, AE-3763, FK-706, ICI-200,880, ZD-0892 and ZD-8321 as the transition-state inhibitors. In this review, various problems that remain to be solved in the clinical use of human neutrophil elastase inhibitors are discussed.

The effects of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review of randomized placebo-controlled trials

Although inhaled corticosteroids are commonly used to treat patients with chronic obstructive pulmonary disease (COPD), their effect on clinical outcomes such as exacerbation and mortality is unknown. This systematic review was conducted to determine whether inhaled corticosteroids improve clinical outcomes for patients with stable COPD. All placebo-controlled randomized trials of inhaled corticosteroids given for at least 6 months for stable COPD were identified by searching MEDLINE (1966-2000), EMBASE (1980-2001), CINAHL (1982-2000), SIGLE (1980-2000), the Cochrane Controlled Trial Registry, and the bibliographies of published studies. We independently extracted data from each of the studies using a specified protocol, and determined the summary risk ratios (RRs) and 95% confidence intervals (CIs) for exacerbations and deaths. Nine randomized trials (3976 patients with COPD), including four with a systemic steroid run-in phase, were identified. Use of inhaled corticosteroid therapy reduced the rate of exacerbations (RR = 0.70; 95% CI: 0.58 to 0.84), with similar benefits in those who were and were not pretreated with systemic steroids. Inhaled corticosteroid therapy was also associated with increased rates of oropharyngeal candidiasis (RR = 2.1; 95% CI: 1.5 to 3.1), skin bruising (RR = 2.1; 95% CI: 1.6 to 2.8), and lower mean cortisol levels. No effects were seen on all-cause mortality (RR = 0.84; 95% CI: 0.60 to 1.18) in the five trials that measured this outcome. This systematic review demonstrates a beneficial effect of inhaled corticosteroids in reducing rates of COPD exacerbation. Further research is required to define the long-term effects of these medications and the benefit/risk ratio for patients with COPD.

Detecting patients at a high risk of developing chronic obstructive pulmonary disease in general practice: cross sectional case finding study

OBJECTIVES

To investigate the effectiveness of case finding of patients at risk of developing chronic obstructive pulmonary disease, whether the method is suitable for use in general practice, how patients should be selected, and the time required.

DESIGN

Cross sectional study.

SETTING

Two semirural general practices in the Netherlands.

PARTICIPANTS

651 smokers aged 35 to 70 years.

MAIN OUTCOME MEASURES

Short standardised questionnaire on bronchial symptoms for current smokers, lung function with a spirometer, and the quality of the spirometric curve.

RESULTS

Of the 201 smokers not taking drugs for a pulmonary condition, 169 produced an acceptable curve (fulfilling American Thoracic Society criteria). Of these, 30 (18%, 95% confidence interval 12% to 24%) had a forced expiratory volume in one second (FEV(1)) <80% of predicted. When smokers were preselected on the basis of chronic cough, the proportion with an FEV(1) <80% of predicted increased to 27% (17 of 64; 12% to 38%). Chronic cough was a better predictor of airflow obstruction than other symptoms, such as wheeze and dyspnoea. The presence of two symptoms was a slightly better predictor than cough only (odds ratio 3.02 (1.37 to 6.64) v 2.50 (1.14 to 5.52)). Age was also a good predictor of obstruction; smokers over 60 with cough had a 48% chance of having an obstruction. The mean time needed for spirometry was four minutes. Detecting one smoker with an FEV(1) <80% of predicted cost 5 pound sterling to 10 pound sterling.

CONCLUSIONS

Trained practice assistants could check all patients who smoke for chronic obstructive pulmonary disease at little cost to the practice. Cough and age are the most important predictors of the disease. By testing one smoker a day, an average practice could identify one patient at risk a week.

Early detection and management of COPD. What you can do to reduce the impact of this disabling disease

Primary care physicians play a pivotal role in the early identification of patients with COPD. Early diagnosis, along with aggressive intervention, is the only way that the increasing morbidity and mortality of COPD can be reversed. Any patient with a history of smoking should undergo evaluation for the possibility of underlying COPD. At minimum, this requires in-office spirometry. Smoking cessation is the most important measure to prevent further deterioration of lung function. Rigorous application of a stepped-care treatment plan can help physicians identify undiagnosed COPD and improve overall quality of life for patients who have symptomatic COPD.

New treatments for COPD

COPD is one of the most common diseases in the world, and there is a global increase in prevalence, but there are no drugs available at present that halt the relentless progression of this disease. However, a better understanding of the cellular and molecular mechanisms that are involved in the underlying inflammatory and destructive processes has revealed several new targets for which drugs are now in development, and the prospects for finding new treatments are good.

Benefits and risks of inhaled corticosteroids in chronic obstructive pulmonary disease

Inhaled corticosteroids have a proven benefit in the management of asthma, but until recently, their efficacy in non-asthmatic, smoking-related chronic obstructive pulmonary disease (COPD) was not evidence-based. Airway inflammation in COPD differs from inflammation in asthma. Some studies have shown an effect of inhaled corticosteroids on airway inflammation in COPD but the clinical relevance of these results are unknown. Short-term studies evaluating the effect of inhaled corticosteroids in patients with COPD were associated with no or modest improvements in lung function. Data from five, long-term, large studies have provided evidence that prolonged treatment with inhaled corticosteroids does not modify the rate of decline of forced expiratory volume in one second (FEV(1)) in patients with COPD and no reversibility to short-acting beta(2)-adrenoceptor agonists. FEV(1) was slightly improved over the first 6 months of treatment in two studies and lower airway reactivity in response to methacholine challenge has been observed. Improvement of respiratory symptoms and health status was also reported in three studies. A reduction in the rate of exacerbations was observed in two studies. No survival benefit was demonstrated in any study. The advantage of using inhaled, rather than oral, corticosteroids is a reduction in adverse effects for the same therapeutic effect, because inhaled corticosteroids rely more on topical action than systemic activity. The long-term safety of inhaled corticosteroids is not known in patients with COPD. However, topical adverse effects, and systemic effects such as a decrease of bone density of lumbar spine and femur and cutaneous adverse effects, have been reported in patients with COPD after 3 years of treatment with inhaled corticosteroids.

COPD in perspective

In the last 200 years or so, the recognition, diagnosis, and understanding of the pathogenesis of COPD have evolved considerably. Over the past few decades, various definitions of COPD and its "components" also have developed. Despite this, however, the treatment options for patients with this relentlessly progressive disorder are relatively limited. In the mid-19th century, the introduction of the spirometer yielded a powerful tool for the diagnosis of COPD. The currently available small, cheap spirometers hold great promise to help patients and their physicians closely monitor lung function. Early recognition of the close associations among emphysema and, more recently, small airways disease, and impaired airflow is discussed. This review also stresses the importance of the identification of COPD in its initial stages and the early onset of appropriate treatment. The therapy for COPD has changed in the last 40 years. Drug therapies in the 1960s included potassium iodide and ephedrine. Corticosteroids were not used, and oxygen therapy and exercise were actually contraindicated. Modern therapy for COPD is now more systematic and includes the use of bronchodilators and corticosteroids to improve airflow, in addition to oxygen therapy, pulmonary rehabilitation and, in selected patients, lung volume reduction surgery. The causal link between the chronic inhalation of tobacco smoke and COPD is beyond doubt, and smoking cessation remains the most important goal for patients. It is hoped that new, more effective therapies will soon be available for the treatment of this disabling disorder to provide improvement in symptoms and patient quality of life and to reduce or stop the rate of disease progression and mortality in patients with COPD.

Cytokines and therapy in COPD: a promising combination?

COPD is a major health problem, with patients showing a progressively declining, largely irreversible, change in lung function. This is associated with chronic airways inflammation and structural remodeling, including loss of alveolar walls, and goblet cell metaplasia with mucus hypersecretion. Inflammatory cells may contribute to the airway remodeling via secretion of proteases, fibrotic or mitogenic growth factors, and cytokines. In turn, airway remodeling may contribute to the clinical symptoms of COPD. Currently available therapies are directed to improvement of clinical symptoms and reduction of the airways inflammation. The commonly used glucocorticosteroids are expected to reduce the inflammation by acting on kinases or transcription factors necessary for expression of pro-inflammatory cytokines or chemokines. However, several long-term and short-term studies showed that glucocorticosteroids are rather ineffective in improving lung function and reducing the airway inflammation in patients with COPD. New therapeutic strategies may reduce the inflammation and alleviate the clinical symptoms of COPD. Tumor necrosis factor-alpha, interleukin-8, and monocyte chemoattractant protein-1 are important chemotactic proteins for macrophages and neutrophils, the predominant inflammatory cells associated with COPD. As lung levels of these cytokines are higher in COPD compared to non-COPD patients, they may represent targets for novel therapies.

Phosphodiesterase 4 inhibitors for the treatment of COPD

Phosphodiesterase 4 (PDE4) is a major cyclic adenosine-3',5'-monophosphate-metabolizing enzyme in immune and inflammatory cells, airway smooth muscle, and pulmonary nerves. Selective inhibitors of this enzyme have been available for a number of years and show a broad spectrum of activity in animal models of COPD and asthma. The class-associated side effects, mainly nausea and emesis, appear to have been at least partially overcome by the so-called "second-generation" PDE4 inhibitors. Currently, three companies are in the later stages of development of candidate second-generation PDE4 inhibitors for the treatment of COPD patients. The preclinical profile of one of these, BAY 19-8004, is summarized below. The initial clinical data on the most advanced compound, cilomilast, were indeed encouraging. However, full knowledge of the therapeutic value of this novel compound class awaits the outcome of longer term clinical trials.

[Effectiveness of inhaled corticosteroids in chronic obstructive lung disease: systematic review]

BACKGROUND

Inhaled corticosteroids are increasingly being used in patients with chronic obstructive lung disease (COPD), but their effectiveness is disputed. The aim of this study was to define the clinical effectiveness of inhaled corticosteroids in non-asthmatic COPD by a systematic review of the literature.

MATERIAL AND METHOD

Literature searches were conducted in Medline, the Cochrane library and the Spanish Medical Index. Only placebo-controlled trials were included. All trials were reviewed by two authors and data were extracted in a pre-defined manner. Meta-analytic techniques were used to estimate global effects when data were comparable.

RESULTS

No clinical trials on the role of inhaled corticosteroids during COPD exacerbations were found. Twelve studies on patients under a stable condition were identified and included in the review. Short-term studies showed that inhaled corticosteroids induced a small increase in FEV1 (average: 96 ml after 1-6 months). Longer term studies indicated that after 1-3 years of continued therapy, FEV1 was higher in treated than in control patients, but the difference was small (51 ml, CI 3-98). There were no consistent effects on symptom scores or the frequency of exacerbations.

CONCLUSION

The results of this review do not support the systematic use of inhaled corticosteroids in patients with non-asthmatic COPD.

New therapeutic drugs in the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease remains a major health problem for which new and improved treatments are desperately needed. Recent trials strongly suggest that treatments are improving. Longer-acting bronchodilators will be more convenient and may have additional advantages. Combinations of bronchodilators may offer additive effects and, possibly, synergies. Inhaled glucocorticoids, although unable to alter the loss of forced expiratory volume in 1 second when used alone, may reduce exacerbation frequency and health status deterioration and improve mortality. These clinically meaningful goals represent end points not previously targeted in chronic obstructive pulmonary disease drug development. Moreover, inhaled glucocorticoids may offer benefits in combination with long-acting beta-agonists. Finally, new classes of agents such as the phosphodiesterase inhibitors are on the horizon. The prospect for better treatment of chronic obstructive pulmonary disease looks brighter than ever. Caution is required, however. Much of the excitement has been generated by small studies, presented only in abstract form, and as yet unpublished work. Therapeutic recommendations will require publication of appropriately designed and adequately powered clinical trials.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) was developed recently to unify international efforts in the management of the disease. The most important GOLD objective is raising awareness that chronic obstructive pulmonary disease is an increasing health problem. The first step in the GOLD program was to prepare a consensus report, named "Global Strategy for the Diagnosis, Management, and Prevention of COPD," based on best-validated evidence and current pathogenetic and clinical knowledge. It encourages implementation of effective strategies for prevention, diagnosis, and management of the disease in all countries, and emphasizes the importance of renewed research initiatives.

Should inhaled corticosteroids be used in the long term treatment of chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a progressive disease with alveolar destruction (emphysema) and bronchiolar fibrosis (obstructive bronchitis) in variable proportions. Reducing disease progression, as assessed by forced expiratory volume in I second (FEV1) decline, health-related quality of life, exacerbation rate and mortality, is a more realistic outcome than physiological improvement. This paper reviews all the published studies of at least 100 patients followed for at least 2 years. Studies have included patients with mild COPD (Copenhagen City Lung Study) to advanced symptomatic disease [Inhaled Steroids in Obstructive Lung Disease (ISOLDE)], with 2 studies of those with relatively early symptoms [European Respiratory Society Study on Chronic Obstructive Pulmonary Disease (EUROSCOP) and Lung Health-21. Exacerbation frequency, and probably severity, are reduced by high dose inhaled corticosteroids. Exacerbations are only frequent in more advanced disease, limiting the use of this outcome in EUROSCOP and Lung Health-2. Exacerbations are associated with reduced health-related quality of life. ISOLDE clearly showed a reduced rate in decline of the disease-specific St George's Respiratory Questionnaire with fluticasone propionate, partly related to the reduced exacerbations. The symptom component of the score showed the greatest difference between placebo and fluticasone propionate. None of the larger studies were able to reproduce the statistically significant reduction in the rate of decline in FEV1 suggested by the smaller, earlier studies. This might at least in part be as a result of the statistical modelling used which cannot adequately compensate for those with more rapidly progressive disease dropping out earlier. The equivalent doses of inhaled corticosteroids differed approximately fivefold between the major studies. The more positive results were obtained with higher doses. Oropharyngeal adverse effects were similar to those seen in patients with asthma; bruising was increased in one study with budesonide, otherwise adverse effects were similar to placebo. Bone loss was specifically studied in subgroups of patients in EUROSCOP and Lung Health-2. Budesonide 800 microg/day was associated with less bone loss than placebo, whereas triamcinolone 1200 microg/day was associated with excess bone loss. High dose inhaled corticosteroids have a favourable risk/benefit ratio in patients with advanced disease, particularly those with frequent exacerbations, and no benefit for those with very mild disease. It is not possible from the data to make firm recommendations for the important intermediate group where delaying progression is likely to lead to greatest benefit. I believe high dose inhaled steroids are warranted for those with intermediate severity COPD, who have frequent exacerbations or significant COPD-related symptoms.

Selective phosphodiesterase inhibitors for the treatment of asthma and chronic obstructive pulmonary disease

Phosphodiesterase type 4 plays an important role in modulating the activity of cells that are involved in the inflammatory processes occurring in chronic obstructive pulmonary disease and asthma. During the past decade, interest has focused on the development of selective inhibitors of phosphodiesterase-4, in an attempt to generate new treatment modalities that control airway inflammation not only in patients with asthma but also in those with chronic obstructive pulmonary disease. The aim of the present review is to discuss the results of recent clinical intervention studies with phosphodiesterase-4 inhibitors in patients with asthma or chronic obstructive pulmonary disease.

Future Advances in COPD Therapy

There is a pressing need for more effective drug treatments for COPD. New bronchodilators include a long-acting anticholinergic tiotropium bromide and a dual beta2-dopamine2-receptor agonist. But no treatments prevent the progression of COPD. Mediator antagonists in development include leukotriene B4 antagonists, chemokine receptor antagonists and more potent antioxidants. The inflammation of COPD is resistant to corticosteroids, so new anti-inflammatory drugs need to be developed. These include phosphodiesterase-4 inhibitors, nuclear factor-kappaB inhibitors and p38 MAP kinase inhibitors. Small molecule protease inhibitors, including neutrophil elastase inhibitors and selective matrix metalloproteinase inhibitors are also in development. Future drug targets may be identified by gene array and proteomics.

The cost effectiveness of early treatment with fluticasone propionate 250 microg twice a day in subjects with obstructive airway disease. Results of the DIMCA program

In a two-stage detection program, subjects with signs of obstructive airway disease were selected from a random sample of the general population. Subjects (n = 82) were randomly assigned to either fluticasone propionate 250 microg twice a day or placebo twice a day via pMDI in a 1-yr, double-blind trial if they met criteria for persistent airway obstruction, increased bronchial hyperresponsiveness, or a rapid decline in FEV(1). Main outcome measures were postbronchodilator FEV(1), quality-adjusted life years (QALYs), and direct medical cost. Secondary measures were prebronchodilator FEV(1), PC(20), health-related quality of life (CRQ), symptom-free weeks, episode-free weeks, exacerbations, and indirect cost. Subgroup analysis was based on reversibility of obstruction. Analysis revealed a significant gain in postbronchodilator FEV(1) (98 ml/yr; p = 0.01) in favor of fluticasone. Only subjects with reversible obstruction showed an improvement in PC(20) (1.4 doubling dose; p = 0.03). Early treatment resulted in 2.7 QALYs gained per 100 treated subjects (p = 0.17) and in a clinically relevant improvement in dyspnea (CRQ; p < 0.03). The incremental cost effectiveness ratios were US$13,016/QALY for early treatment and US$33,921/QALY for the combination of detection and treatment. The incremental cost for one additional subject with a clinically relevant difference in dyspnea was US$1,674. In conclusion, early intervention with fluticasone resulted in significant health gains at relatively low financial cost.

Repeatability of lung density measurements with low-dose computed tomography in subjects with alpha-1-antitrypsin deficiency-associated emphysema

RATIONALE AND OBJECTIVES

Multislice computed tomography (MSCT) of the lungs provides a new opportunity for longitudinal assessment of lung densities because of shorter scan duration. The aim of the present study was to assess the intraindividual variation of lung densities measured by MSCT of patients with emphysema.

METHODS

Ten patients with emphysema participated in a study in which MSCT was obtained on two occasions, approximately 2 weeks apart. Scanning parameters were 140 kV, 20 mAs, 4 x 2.5-mm collimation, and effective slice thickness of 2.5 mm. Lung density was measured as the 15th percentile point and the relative area below -910 Hounsfield units (HU) by using Pulmo-LKEB software.

RESULTS

The mean difference of the 15th percentile point was -1.29 +/- 3.2 HU, and that for the relative area below the -910-HU parameter was -1.02% +/- 3.09%. Intraclass coefficients of variation were 0.96 (0.86-0.99) and 0.94 (0.8-0.98), respectively (95% confidence interval).

CONCLUSIONS

Lung density parameters of emphysema derived by MSCT provide an opportunity for analysis of the treatment effects of new drugs on the progression of emphysema.

Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study

Although exacerbation of chronic obstructive pulmonary disease (COPD) is important in terms of health and costs, there is little information about which are the risk factors. We estimated the association between modifiable and nonmodifiable potential risk factors of exacerbation and the admission for a COPD exacerbation, using a case-control approach. Cases were recruited among admissions for COPD exacerbation during 1 yr in four tertiary hospitals of the Barcelona area. Control subjects were recruited from hospital's register of discharges, having coincided with the referent case in a previous COPD admission but being clinically stable when the referent case was hospitalized. All patients completed a questionnaire and performed spirometry, blood gases, and physical examination. Information about potential risk factors was collected, including variables related to clinical status, characteristics of medical care, medical prescriptions, adherence to medication, lifestyle, quality of life, and social support. A total of 86 cases and 86 control subjects were included, mean age 69 yr, mean FEV(1) 39% of predicted. Multivariate logistic regression showed the following risk (or protective) factors of COPD hospitalization: three or more COPD admissions in the previous year (odds ratio [OR] 6.21, p = 0.008); FEV(1) (OR 0.96 per percentual unit, p < 0.0005); underprescription of long-term oxygen therapy (LTOT) (OR 22.64, p = 0.007); and current smoking (OR 0.30, p = 0.022). Among a wide range of potential risk factors we have found that only previous admissions, lower FEV(1), and underprescription of LTOT are independently associated with a higher risk of admission for a COPD exacerbation.