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Single-inhaler triple therapy in patients with chronic obstructive pulmonary disease: a systematic review. Respir Res 2019; 20:242. [PMID: 31684965 PMCID: PMC6829989 DOI: 10.1186/s12931-019-1213-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Guidelines recommend that treatment with a long-acting β2 agonist (LABA), a long-acting muscarinic antagonist (LAMA), and inhaled corticosteroids (ICS), i.e. triple therapy, is reserved for a select group of symptomatic patients with chronic obstructive pulmonary disease (COPD) who continue to exacerbate despite treatment with dual therapy (LABA/LAMA). A number of single-inhaler triple therapies are now available and important clinical questions remain over their role in the patient pathway. We compared the efficacy and safety of single-inhaler triple therapy to assess the magnitude of benefit and to identify patients with the best risk-benefit profile for treatment. We also evaluated and compared study designs and population characteristics to assess the strength of the evidence base. Methods We conducted a systematic search, from inception to December 2018, of randomised controlled trials (RCTs) of single-inhaler triple therapy in patients with COPD. The primary outcome was the annual rate of moderate and severe exacerbations. Results We identified 523 records, of which 15 reports/abstracts from six RCTs were included. Triple therapy resulted in the reduction of the annual rate of moderate or severe exacerbations in the range of 15–52% compared with LAMA/LABA, 15–35% compared to LABA/ICS and 20% compared to LAMA. The patient-based number needed to treat for the moderate or severe exacerbation outcome ranged between approximately 25–50 (preventing one patient from having an event) and the event-based number needed to treat of around 3–11 (preventing one event). The absolute benefit appeared to be greater in patients with higher eosinophil counts or historical frequency of exacerbations and ex-smokers. In the largest study, there was a significantly higher incidence of pneumonia in the triple therapy arm. There were important differences in study designs and populations impacting the interpretation of the results and indicating there would be significant heterogeneity in cross-trial comparisons. Conclusion The decision to prescribe triple therapy should consider patient phenotype, magnitude of benefit and increased risk of adverse events. Future research on specific patient phenotype thresholds that can support treatment and funding decisions is now required from well-designed, robust, clinical trials. Trial registration PROSPERO #CRD42018102125.
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Bourbeau J, Bhutani M, Hernandez P, Aaron SD, Balter M, Beauchesne MF, D’Urzo A, Goldstein R, Kaplan A, Maltais F, Sin DD, Marciniuk DD. Canadian Thoracic Society Clinical Practice Guideline on pharmacotherapy in patients with COPD – 2019 update of evidence. CANADIAN JOURNAL OF RESPIRATORY CRITICAL CARE AND SLEEP MEDICINE 2019. [DOI: 10.1080/24745332.2019.1668652] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Jean Bourbeau
- Research Institute of the McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Mohit Bhutani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shawn D. Aaron
- The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Meyer Balter
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Anthony D’Urzo
- Primary Care Lung Clinic, University of Toronto, Toronto, Ontario, Canada
| | - Roger Goldstein
- West Park Healthcare Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, Ontario, Canada
| | - François Maltais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Quebec, Canada
| | - Don D. Sin
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Darcy D. Marciniuk
- Respiratory Research Centre, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Zayed Y, Barbarawi M, Kheiri B, Haykal T, Chahine A, Rashdan L, Hamid K, Sundus S, Banifadel M, Aburahma A, Bachuwa G, Chandran A. Triple versus dual inhaler therapy in moderate-to-severe COPD: A systematic review and meta-analysis of randomized controlled trials. CLINICAL RESPIRATORY JOURNAL 2019; 13:413-428. [PMID: 30947394 DOI: 10.1111/crj.13026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/21/2019] [Accepted: 03/24/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Treatment of chronic obstructive pulmonary disease (COPD) is evolving specially with triple inhaler therapy. OBJECTIVES To perform a meta-analysis to ascertain the safety and efficacy of triple inhaler therapy consisting of an inhaled-glucocorticoid (ICS), long-acting muscarinic antagonist (LAMA) and long-acting beta2-agonist (LABA) when compared with dual therapy (ICS-LABA or LAMA-LABA). METHODS We performed an electronic database search to include randomized controlled trials (RCTs) comparing between triple and dual inhalers. Pooled rate-ratio (RR) or odds-ratio (OR) for dichotomous data and weighted mean difference (MD) for continuous data were calculated with their corresponding 95% confidence interval (CI). RESULTS Our study included 12 RCTs totaling 19,322 patients, mean age of 65 ± 8.2 years and 68.2% were male. Pooled analysis demonstrated a significant reduction in moderate-to-severe COPD exacerbations with triple therapy (RR 0.75; 95% CI 0.69-0.83; P < 0.01). Additionally, triple therapy caused significant increase in trough FEV1 (MD 0.09 L; 95% CI 0.07-0.12; P < 0.01), significant reduction in the mean St. George's Respiratory Questionnaire (SGRQ) score (MD -1.67; 95% CI -2.02- -1.31; P < 0.01), and more patients experienced ≥ 4 points reduction of SGRQ score (OR 1.27; 95% CI 1.19-1.35; P < 0.01). Triple therapy was associated with an increased risk of pneumonia when compared to LABA/LAMA (OR 1.25; 95% 1.03-1.97; P = 0.03) but there were no significant differences in other adverse events between triple and dual inhalers. CONCLUSIONS Among patients with moderate-to-severe COPD, triple inhaler therapy was associated with a reduction of moderate-to-severe COPD exacerbations, improved lung function and improved quality of life when compared to dual inhaler therapy but with an increased pneumonia risk.
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Affiliation(s)
- Yazan Zayed
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Mahmoud Barbarawi
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Tarek Haykal
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Adam Chahine
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Laith Rashdan
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Kewan Hamid
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Saira Sundus
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Momen Banifadel
- Internal Medicine Department, University of Toledo, Toledo, Ohio
| | - Ahmed Aburahma
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Arul Chandran
- Pulmonary and Critical Care Department, Hurley Medical Center, Michigan State University, Flint, Michigan
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Lane DC, Stemkowski S, Stanford RH, Tao Z. Initiation of Triple Therapy with Multiple Inhalers in Chronic Obstructive Pulmonary Disease: An Analysis of Treatment Patterns from a U.S. Retrospective Database Study. J Manag Care Spec Pharm 2019; 24:1165-1172. [PMID: 30362922 PMCID: PMC10397697 DOI: 10.18553/jmcp.2018.24.11.1165] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Evidence suggests that real-world treatment patterns of chronic obstructive pulmonary disease (COPD) do not always follow evidence-based treatment recommendations such as those of the Global Initiative for Chronic Obstructive Lung Disease, which recommends treatment escalation based on disease progression. This U.S. database study evaluated treatment patterns in patients with COPD, focusing on time to initiation of triple therapy using multiple inhalers. OBJECTIVES To (a) estimate time from diagnosis to initiation of long-acting muscarinic antagonist (LAMA) monotherapy, inhaled corticosteroid (ICS)/long-acting beta2-agonist (LABA) dual therapy, or LAMA/LABA dual therapy; (b) estimate time to initiation of triple therapy from LAMA monotherapy and ICS/LABA or LAMA/LABA dual therapies; and (c) estimate the likelihood of patient progression to triple therapy. METHODS This study was a retrospective analysis of patients with COPD newly started on LAMA monotherapy, ICS/LABA, or LAMA/LABA therapy between July 1, 2010, and March 31, 2013, as identified in Humana's research database. Patients who were fully insured with commercial or Medicare Advantage insurance plans and were aged ≥ 40 years at index with at least 1 hospitalization, 1 emergency department, or 1 medical office visit claim with a COPD diagnosis in the pre-index year were included in the analysis. Time from diagnosis to initiation of index therapy and time to triple therapy after index therapy were assessed. Multivariable logistic regression models were used to estimate the likelihood of progression to triple therapy. RESULTS Of 13,541 patients with a confirmed diagnosis of COPD, 4,000 received LAMA monotherapy; 8,207 received ICS/LABA therapy; and 77 received LAMA/LABA therapy at index; mean time (± SD) from COPD diagnosis to initiation of triple therapy was 178 (± 134) days, 185 (± 130) days, and 252 (± 124) days, respectively. During the study, 28% (n = 1,130) of patients receiving LAMA monotherapy and 20% (n = 1,647) of patients receiving dual therapy (ICS/LABA, n = 1,615; LAMA/LABA, n = 32) progressed to triple therapy. Of the patients who progressed to triple therapy, 63% and 57% of patients receiving monotherapy and dual therapy, respectively, progressed in the 12 months after the index date. In the 12 months before initiation of triple therapy, approximately 50% of patients in the LAMA monotherapy, ICS/LABA, and LAMA/LABA therapy groups had an exacerbation. In the multivariable analysis, discontinuation of therapy, smoking history, and concomitant use of xanthenes and short-acting beta2-agonists were significant predictors of progression from index therapy to triple therapy. CONCLUSIONS Approximately 25% of patients with COPD progressed to triple therapy within 12 months of initiating treatment with monotherapy or dual therapy. Exacerbations were reported in only 50% of these patients, indicating that the other 50% may have escalated to triple therapy for other reasons. Treatment discontinuation, smoking history, the use of a LAMA, and concomitant medication use were significant predictors of progression to triple therapy. DISCLOSURES This study was a GlaxoSmithKline-sponsored collaborative research study (HO-14-16145). GlaxoSmithKline funded this study and had a role in study design, data analysis, data interpretation, and writing of this report. Stemkowski is a paid employee of Comprehensive Health Insights, which is a wholly owned subsidiary of Humana and was contracted to conduct the study. No funding was provided to Comprehensive Health Insights for manuscript development. At the time of the study, Lane and Tao were paid employees of Comprehensive Health Insights. Stanford is an employee of and stockholder in GlaxoSmithKline.
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Affiliation(s)
- Daniel C Lane
- 1 Comprehensive Health Insights, Humana, Louisville, Kentucky
| | | | | | - Zhuliang Tao
- 1 Comprehensive Health Insights, Humana, Louisville, Kentucky
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Zheng Y, Zhu J, Liu Y, Lai W, Lin C, Qiu K, Wu J, Yao W. Triple therapy in the management of chronic obstructive pulmonary disease: systematic review and meta-analysis. BMJ 2018; 363:k4388. [PMID: 30401700 PMCID: PMC6218838 DOI: 10.1136/bmj.k4388] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the rate of moderate to severe exacerbations between triple therapy and dual therapy or monotherapy in patients with chronic obstructive pulmonary disease (COPD). DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES PubMed, Embase, Cochrane databases, and clinical trial registries searched from inception to April 2018. ELIGIBILITY CRITERIA Randomised controlled trials comparing triple therapy with dual therapy or monotherapy in patients with COPD were eligible. Efficacy and safety outcomes of interest were also available. DATA EXTRACTION AND SYNTHESIS Data were collected independently. Meta-analyses were conducted to calculate rate ratios, hazard ratios, risk ratios, and mean differences with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations assessment, development, and evaluation). RESULTS 21 trials (19 publications) were included. Triple therapy consisted of a long acting muscarinic antagonist (LAMA), long acting β agonist (LABA), and inhaled corticosteroid (ICS). Triple therapy was associated with a significantly reduced rate of moderate or severe exacerbations compared with LAMA monotherapy (rate ratio 0.71, 95% confidence interval 0.60 to 0.85), LAMA and LABA (0.78, 0.70 to 0.88), and ICS and LABA (0.77, 0.66 to 0.91). Trough forced expiratory volume in 1 second (FEV1) and quality of life were favourable with triple therapy. The overall safety profile of triple therapy is reassuring, but pneumonia was significantly higher with triple therapy than with dual therapy of LAMA and LABA (relative risk 1.53, 95% confidence interval 1.25 to 1.87). CONCLUSIONS Use of triple therapy resulted in a lower rate of moderate or severe exacerbations of COPD, better lung function, and better health related quality of life than dual therapy or monotherapy in patients with advanced COPD. STUDY REGISTRATION Prospero CRD42018077033.
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Affiliation(s)
- Yayuan Zheng
- Laboratory of Physiological Sciences and Department of Pharmacy of the Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang, China
| | - Jianhong Zhu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuyu Liu
- Department of Pharmacology, Guangdong Medical University, Zhanjiang, China
| | - Weiguang Lai
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
| | - Chunyu Lin
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
| | - Kaifen Qiu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junyan Wu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Weimin Yao
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
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Molino A, Calabrese G, Maniscalco M. Patient considerations in the treatment of COPD: focus on the new combination inhaler fluticasone furoate/umeclidinium/vilanterol. Patient Prefer Adherence 2018; 12:993-1001. [PMID: 29922045 PMCID: PMC5997126 DOI: 10.2147/ppa.s152179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The pharmacological treatment for stable COPD is based on the use of inhaled bronchodilators (long-acting muscarinic receptor antagonists and long-acting beta-2 adrenoceptor agonists) and inhaled corticosteroids. The use of triple inhaled therapy is recommended to selected patients with COPD. Among the various inhaler combinations in triple therapy, a new combination by fluticasone furoate, umeclidinium, and vilanterol is available for COPD patients. Recently, a large clinical trial using this combination has been published, resulting in a reduction in exacerbation rate in COPD patients. Furthermore, this combination has demonstrated efficacy and safety, with a single administration a day, through a dry powder inhalator device, which has shown a good adherence and is a preference of the patient. This review focuses on the main characteristics of this inhaler combination evaluating the main clinical effects, the patients' adherence, and the safety.
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Affiliation(s)
- Antonio Molino
- Division of Pneumology, Department of Respiratory Diseases, University of Naples Federico II, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Giovanna Calabrese
- Division of Pneumology, Department of Respiratory Diseases, University of Naples Federico II, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Mauro Maniscalco
- Pulmonary Rehabilitation Division, ICS Maugeri SpA SB, Institute of Telese Terme, Telese Terme, Benevento, Italy
- Correspondence: Mauro Maniscalco, Via Bagni Vecchi 1, 82037 Telese Terme, Benevento, Italy, Tel/fax +39 8 2490 9350, Email
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Malerba M, Nardin M, Santini G, Mores N, Radaeli A, Montuschi P. Single-inhaler triple therapy utilizing the once-daily combination of fluticasone furoate, umeclidinium and vilanterol in the management of COPD: the current evidence base and future prospects. Ther Adv Respir Dis 2018; 12:1753466618760779. [PMID: 29537340 PMCID: PMC5941662 DOI: 10.1177/1753466618760779] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/31/2018] [Indexed: 12/13/2022] Open
Abstract
Maintenance pharmacological treatment for stable chronic obstructive pulmonary disease (COPD) is based on inhaled drugs, including long-acting muscarinic receptor antagonists (LAMA), long-acting β2-adrenoceptor agonists (LABA) and inhaled corticosteroids (ICS). Inhaled pharmacological treatment can improve patients' daily symptoms and reduce decline of pulmonary function and acute exacerbation rate. Treatment with all three inhaled drug classes is reserved for selected, more severe, patients with COPD when symptoms are not sufficiently controlled by dual LABA/LAMA therapy and exacerbations are frequent. This review focuses on the role of single-inhaler triple therapy with once-daily fluticasone furoate/umeclidinium/vilanterol fixed-dose combination, which is in phase III clinical development for maintenance treatment of severe-to-very severe COPD. In this review, we summarize evidence providing the rationale for its use in COPD and discuss the gaps to be filled in this pharmacotherapeutic area.
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Affiliation(s)
- Mario Malerba
- Department of Translational Medicine-Respiratory Medicine, University of Piemonte Orientale, Novara/Vercelli, Italy
| | - Matteo Nardin
- Department of Internal Medicine, University of Brescia, Brescia, Italy
| | - Giuseppe Santini
- Department of Pharmacology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation, Rome, Italy
| | - Nadia Mores
- Department of Pharmacology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation, Rome, Italy
| | - Alessandro Radaeli
- Department of Emergency Medicine, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Paolo Montuschi
- Department of Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Agostino Gemelli, University Hospital Foundation, Largo Francesco Vito, 1 – 00168, Rome, Italy
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Bourbeau J, Bhutani M, Hernandez P, Marciniuk DD, Aaron SD, Balter M, Beauchesne MF, D'Urzo A, Goldstein R, Kaplan A, Maltais F, O'Donnell DE, Sin DD. CTS position statement: Pharmacotherapy in patients with COPD—An update. CANADIAN JOURNAL OF RESPIRATORY CRITICAL CARE AND SLEEP MEDICINE 2017. [DOI: 10.1080/24745332.2017.1395588] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jean Bourbeau
- McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | | | | | - Darcy D. Marciniuk
- Respiratory Research Centre, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shawn D. Aaron
- The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Meyer Balter
- Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | | | - Anthony D'Urzo
- Primary Care Lung Clinic, University of Toronto, Toronto, Ontario, Canada
| | - Roger Goldstein
- West Park Healthcare Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, Ontario, Canada
| | - François Maltais
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec, Canada
| | | | - Don D. Sin
- University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
Chronic airway diseases are a significant cause of morbidity and mortality worldwide, and their prevalence is predicted to increase in the future. Respiratory viruses are the most common cause of acute pulmonary infection, and there is clear evidence of their role in acute exacerbations of inflammatory airway diseases such as asthma and chronic obstructive pulmonary disease. Studies have reported impaired host responses to virus infection in these diseases, and a better understanding of the mechanisms of these abnormal immune responses has the potential to lead to the development of novel therapeutic targets for virus-induced exacerbations. The aim of this article is to review the current knowledge regarding the role of viruses and immune modulation in acute exacerbations of chronic pulmonary diseases and to discuss exciting areas for future research and novel treatments.
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Rojas‐Reyes MX, García Morales OM, Dennis RJ, Karner C. Combination inhaled steroid and long-acting beta₂-agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016; 2016:CD008532. [PMID: 27271056 PMCID: PMC6481546 DOI: 10.1002/14651858.cd008532.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The long-acting bronchodilator tiotropium and single-inhaler combination therapy of inhaled corticosteroids and long-acting beta2-agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. OBJECTIVES To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD.• Tiotropium plus LABA/ICS versus tiotropium.• Tiotropium plus LABA/ICS versus LABA/ICS. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov (www.ClinicalTrials.gov), the World Health Organization (WHO) trials portal and reference lists of relevant articles. SELECTION CRITERIA We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. DATA COLLECTION AND ANALYSIS We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. MAIN RESULTS Tiotropium plus LABA/ICS versus tiotropiumWe included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long-acting beta2-agonist combination therapy versus tiotropium alone. Investigators found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants), a reduction in all-cause hospitalisations with the use of combined therapy (tiotropium + LABA/ICS) (OR 0.61, 95% CI 0.40 to 0.92; two studies; 961 participants; number needed to treat for an additional beneficial outcome (NNTB) 19.7, 95% CI 10.75 to 123.41). The effect on exacerbations was heterogeneous among trials and was not meta-analysed. Health-related quality of life measured by St. George's Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) -3.46, 95% CI -5.05 to -1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome.A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICSOne of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. AUTHORS' CONCLUSIONS In this update, we found new moderate-quality evidence that combined tiotropium + LABA/ICS therapy compared with tiotropium plus placebo decreases hospital admission. Low-quality evidence suggests an improvement in disease-specific quality of life with combined therapy. However, evidence is insufficient to support the benefit of tiotropium + LABA/ICS for mortality and exacerbations (moderate- and low-quality evidence, respectively). Of note, not all participants enrolled in the included studies would be candidates for triple therapy according to current international guidance.Compared with the use of tiotropium plus placebo, tiotropium + LABA/ICS-based therapy does not increase undesirable effects such as adverse events or serious non-fatal adverse events.
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Affiliation(s)
- Maria Ximena Rojas‐Reyes
- Pontificia Universidad JaverianaDepartment of Clinical Epidemiology and Biostatistics, Faculty of MedicineCr. 7 #40‐62, 2nd floorBogotáDCColombia
| | - Olga M García Morales
- Faculty of Medicine, Pontificia Universidad JaverianaDepartment of Internal MedicineBogotáColombia
| | - Rodolfo J Dennis
- Pontificia Universidad JaverianaDepartment of Clinical Epidemiology and Biostatistics, Faculty of MedicineCr. 7 #40‐62, 2nd floorBogotáDCColombia
- Fundacion Cardioinfantil Instituto de CardiologiaResearch DepartmentBogotaColombia
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11
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Abstract
Chronic obstructive pulmonary disease (COPD) is a major cause of death and disability worldwide. Inhaled bronchodilators are the mainstay of COPD pharmacological treatment. Long-acting muscarinic antagonists (LAMAs) are a major class of inhaled bronchodilators. Some LAMA/device systems with different characteristics and dosing schedules are currently approved for maintenance therapy of COPD and a range of other products are being developed. They improve lung function and patient-reported outcomes and reduce acute bronchial exacerbations with good safety. LAMAs are used either alone or associated with long-acting β₂-agonists, eventually in fixed dose combinations. Long-acting β₂-agonist/LAMA combinations assure additional benefits over the individual components alone. The reader will obtain a view of the safety and efficacy of the different LAMA/device systems in COPD patients.
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Affiliation(s)
- Andrea S Melani
- Dipartimento Vasi, Cuore e Torace, Fisiopatologia e Riabilitazione Respiratoria, Policlinico Le Scotte, Azienda Ospedaliera Universitaria Senese, Viale Bracci Siena, Italy
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Kwak MS, Kim E, Jang EJ, Kim HJ, Lee CH. The efficacy and safety of triple inhaled treatment in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis using Bayesian methods. Int J Chron Obstruct Pulmon Dis 2015; 10:2365-76. [PMID: 26604734 PMCID: PMC4639518 DOI: 10.2147/copd.s93191] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Although tiotropium (TIO) and inhaled corticosteroid (ICS)/long-acting β-agonists are frequently prescribed together, the efficacy of "triple therapy" has not been scientifically demonstrated. We conducted a systematic review and meta-analysis using Bayesian methods to compare triple therapy and TIO monotherapy. METHODS We searched the MEDLINE, EMBASE, and Cochrane Library databases for randomized controlled trials comparing the efficacy and safety of triple therapy and TIO monotherapy in patients with chronic obstructive pulmonary disease (COPD). We conducted a meta-analysis to compare the effectiveness and safety of triple therapy and TIO monotherapy using Bayesian random effects models. RESULTS Seven trials were included, and the risk of bias in the majority of the studies was acceptable. There were no statistically significant differences in the incidence of death and acute exacerbation of disease in the triple therapy and TIO monotherapy groups. Triple therapy improved the prebronchodilator forced expiratory volume in 1 second (mean difference [MD], 63.68 mL; 95% credible interval [CrI], 45.29-82.73), and patients receiving triple therapy showed more improvement in St George Respiratory Questionnaire scores (MD, -3.11 points; 95% CrI, -6.00 to -0.80) than patients receiving TIO monotherapy. However, both of these differences were lower than the minimal clinically important difference (MCID). No excessive adverse effects were reported in triple therapy group. CONCLUSION Triple therapy with TIO and ICSs/long-acting β-agonists was only slightly more efficacious than TIO monotherapy in treating patients with COPD. Further investigations into the efficacy of new inhaled drugs are needed.
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Affiliation(s)
- Min-Sun Kwak
- Department of Internal Medicine, Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eunyoung Kim
- Department of Statistics, Kyungpook National University, Daegu, Republic of Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Republic of Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Cazzola M, Matera MG. Triple combinations in chronic obstructive pulmonary disease – is three better than two? Expert Opin Pharmacother 2014; 15:2475-8. [DOI: 10.1517/14656566.2014.972367] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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