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Zhai C, Wang F, Xu R, Sun X, Ma W, Wang L. Umeclidinium plus vilanterol versus fluticasone propionate plus salmeterol for chronic obstructive pulmonary disease: a meta-analysis of randomized, controlled trials. Postgrad Med J 2024:qgae054. [PMID: 38652265 DOI: 10.1093/postmj/qgae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/27/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Umeclidinium plus vilanterol (UMEC/VI) is an inhaled long-acting muscarinic antagonist/long-acting beta2-agonist (LAMA/LABA), recently approved as once-daily maintenance therapy for chronic obstructive pulmonary disease (COPD). This meta-analysis aims to assess the efficacy and safety of UMEC/VI compared with fluticasone propionate plus salmeterol (FP/SAL). METHODS A systematic search was conducted by a trained medical research librarian across MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese Biomedical Literature Database (CBM) for randomized controlled trials comparing UMEC/VI with FP/SAL in COPD patients. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was 0-24 h weighted mean (wm) forced expiratory volume in the first second (FEV1), trough FEV1. The secondary outcomes were other lung functions, symptoms, quality of life, and safety. RESULTS Three studies with 2119 patients were included in the meta-analysis. UMEC/VI showed improvement in 0-24 h wm FEV1 (mean difference (MD) 0.08 L, 95% confidence interval (CI) 0.06 to 0.10, P < 0.01, moderate quality) and trough FEV1 (MD 0.09 L, 95% CI 0.07 to 0.11, P < 0.01, moderate quality) in comparison with FP/SAL. UMEC/VI statistically significantly improved all other lung functions compared with FP/SAL. However, there were no significant differences between UMEC/VI and FP/SAL in rescue-medication use, symptomatic endpoints, and health outcomes. UMEC/VI also demonstrated fewer drug-related adverse effects (risk ratio 0.47, 95% CI 0.27 to 0.82, P = 0.01, low quality). CONCLUSIONS UMEC/VI, when compared with FP/SAL, demonstrated significant improvements in lung functions with fewer drug-related adverse effects. However, the conclusion was limited by the scarcity of studies and long-term trials.
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Affiliation(s)
- Chunjuan Zhai
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Huaiyin District, 250021, Jinan, Shandong, China
| | - Fen Wang
- Department of Infection Management, Weishan People's Hospital, No. 10 Chenghou Road, Xiazhen Street, Weishan County, 277600, Jining, Shandong, China
| | - Ruie Xu
- Department of Respiratory, Heze Municipal Hospital, No. 2888 Caozou, Mudan District, 274031, Heze, Shandong, China
| | - Xia Sun
- Department of Geriatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Huaiyin District, 250021, Jinan, Shandong, China
| | - Wenbin Ma
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, No. 1166 Liutai Avenue, Wenjiang District, 611137, Chengdu, Sichuan, China
| | - Li Wang
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Huaiyin District, 250021, Jinan, Shandong, China
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Bogart M, Leung GYH, Cyhaniuk A, DiRocco K. Inpatient Admissions and Re-Admissions in Medicare Beneficiaries Initiating Umeclidinium/Vilanterol or Tiotropium Therapy. Int J Chron Obstruct Pulmon Dis 2024; 19:439-450. [PMID: 38374817 PMCID: PMC10874883 DOI: 10.2147/copd.s436654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/10/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose Patients with chronic obstructive pulmonary disease (COPD) who are hospitalized are more likely to die from their illness and have increased likelihood of re-admission than those who are not. Subsequent re-admissions further increase the burden on healthcare systems. This study compared inpatient admission rates and time-to-first COPD-related inpatient admission among Medicare beneficiaries with COPD indexed on umeclidinium/vilanterol (UMEC/VI) versus tiotropium (TIO). Patients and Methods This retrospective study used the All-Payer Claims Database to investigate hospital admission and re-admission outcomes in Medicare beneficiaries with COPD with an initial pharmacy claim for UMEC/VI or TIO from 1 January 2015 to 28 February 2020. Inpatient admissions, baseline, and follow-up variables were assessed in patients indexed on UMEC/VI and TIO after propensity score matching (PSM), with time-to-first on-treatment COPD-related inpatient admission as the primary endpoint. Re-admissions were assessed among patients with a COPD-related inpatient admission in the 30- and 90-days post-discharge. Results Post-PSM, 7152 patients indexed on UMEC/VI and 7069 on TIO were eligible for admissions analysis. The mean (standard deviation [SD]) time-to-first COPD-related inpatient admission was 46.71 (87.99) days for patients indexed on UMEC/VI and 44.96 (85.90) days for those on TIO (p=0.06). The mean (SD) number of inpatient admissions per patient was 1.24 (2.92) for patients indexed on UMEC/VI and 1.26 (3.05) for those on TIO (p=0.49). Proportion of patients undergoing re-admissions was similar between treatments over both 30 and 90 days, excluding a significantly lower proportion of patients indexed on UMEC/VI than those indexed on TIO for COPD-related re-admissions for hospital stays of 4-7 days and 7-14 days, and all-cause re-admissions for stays of 4-7 days. Conclusion Patients with COPD using Medicare in the US and receiving UMEC/VI or TIO reported similar time-to-first inpatient admission and similar proportion of re-admissions.
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Affiliation(s)
- Michael Bogart
- Customer Engagement, Value, Evidence and Outcomes (CEVEO) US Medical Affairs, GSK, Research Triangle Park, NC, USA
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Yang M, Li Y, Jiang Y, Guo S, He JQ, Sin DD. Combination therapy with long-acting bronchodilators and the risk of major adverse cardiovascular events in patients with COPD: a systematic review and meta-analysis. Eur Respir J 2023; 61:2200302. [PMID: 36137586 DOI: 10.1183/13993003.00302-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 09/07/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Accumulated high-quality data from randomised controlled trials (RCTs) indicate that long-acting muscarinic antagonist (LAMA)/long-acting β2 agonist (LABA) combination therapy significantly improves clinical symptoms and health status in patients with chronic obstructive pulmonary disease (COPD) and reduces exacerbation risk. However, there is a growing concern that LAMA/LABA therapy may increase the risk of cardiovascular disease in patients with COPD. The aim of this paper is to determine whether the use of LAMA/LABA combination therapy modifies the risk of cardiovascular disease in patients with COPD. METHODS Two reviewers independently searched Embase, PubMed and Cochrane Library to identify relevant RCTs of LAMA/LABA or LABA/LAMA/inhaled corticosteroids (ICS) for the management of patients with COPD that reported on cardiovascular end-points. The primary outcome was major adverse cardiovascular events (MACE), which was a composite of cardiovascular death, myocardial infarction or stroke. RESULTS A total of 51 RCTs enrolling 91 021 subjects were analysed. Both dual LAMA/LABA (1.6% versus 1.3%; relative risk 1.42, 95% CI 1.11-1.81) and triple therapy (1.6% versus 1.4%; relative risk 1.29, 95% CI 1.03-1.61) significantly increased the risk of MACE compared with ICS/LABA. The excess risk was most evident in RCTs in which the average underlying baseline risk for MACE was >1% per year. Compared with LAMA only, LABA only or placebo, dual LAMA/LABA therapy did not significantly increase the risk of MACE, though these comparisons may have lacked sufficient statistical power. CONCLUSION Compared with ICS/LABA, dual LAMA/LABA or triple therapy increases cardiovascular risk in patients with COPD. This should be considered in the context of the incremental benefits of these therapies for symptoms and exacerbation rates in patients with COPD, especially in those with a MACE risk of >1% per year.
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Affiliation(s)
- Mingjin Yang
- Dept of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Mingjin Yang, Yishi Li and Youfan Jiang are joint first authors
| | - Yishi Li
- Dept of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Mingjin Yang, Yishi Li and Youfan Jiang are joint first authors
| | - Youfan Jiang
- Dept of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Mingjin Yang, Yishi Li and Youfan Jiang are joint first authors
| | - Shuliang Guo
- Dept of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Shuliang Guo, Jian-Qing He and Don D. Sin contributed equally to this article as lead authors and supervised the work
| | - Jian-Qing He
- Dept of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
- Shuliang Guo, Jian-Qing He and Don D. Sin contributed equally to this article as lead authors and supervised the work
| | - Don D Sin
- Division of Respiratory Medicine, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada
- Shuliang Guo, Jian-Qing He and Don D. Sin contributed equally to this article as lead authors and supervised the work
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Tanimura K, Sato S, Fujita Y, Yamamoto Y, Hajiro T, Horita N, Kawayama T, Muro S. The efficacy and safety of additional treatment with short-acting muscarinic antagonist combined with long-acting beta-2 agonist in stable patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Chron Respir Dis 2023; 20:14799731231166008. [PMID: 36967224 PMCID: PMC10052583 DOI: 10.1177/14799731231166008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The rationale for additional treatment with short-acting bronchodilators combined with long-acting bronchodilators for patients with chronic obstructive pulmonary disease (COPD) is not adequately studied. METHODS We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of a short-acting muscarinic antagonist (SAMA) therapy combined with a long-acting beta-2 agonist (LABA) in patients with stable COPD. Pulmonary function, dyspnea, health-related quality of life, exercise tolerance, physical activity, exacerbations of COPD, and adverse events during regular use were set as outcomes of interest. RESULTS We included five controlled trials including two sets of publicly available online data without article publications for the meta-analysis. Additional use of SAMA plus LABA showed a significant improvement in the peak response in FEV1 (mean difference (MD) 98.70 mL, p < .00001), transitional dyspnea index score (MD .85, p = .02), and St George's Respiratory Questionnaire score (MD -2.00, p = .008) compared to LABA treatment. There was no significant difference in the risk of exacerbation of COPD (p = .20) and only a slight trend of increased severe adverse events (OR: 2.16, p = .08) and cardiovascular events (OR: 2.38, p = .06). CONCLUSION Additional treatment with SAMA combined with LABA could be a feasible choice due to its efficacy and safety.
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Affiliation(s)
- Kazuya Tanimura
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukio Fujita
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
| | - Yoshifumi Yamamoto
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
| | - Takashi Hajiro
- Department of Respiratory Medicine, 13802Tenri Hospital, Tenri, Japan
| | - Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, 26333Kurume University School of Medicine, Kurume, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
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The Efficacy and Cost-Effectiveness of Umeclidinium/Vilanterol versus Tiotropium in Symptomatic Patients with Chronic Obstructive Pulmonary Disease. Can Respir J 2022; 2022:2878648. [PMID: 36060827 PMCID: PMC9436597 DOI: 10.1155/2022/2878648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/10/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022] Open
Abstract
Background Both long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) are widely used in the treatment of chronic obstructive pulmonary disease (COPD). A novel LAMA/LABA combination of umeclidinium/vilanterol (UMEC/VI; 62.5 μg/25 μg) is approved for chronic obstructive pulmonary disease (COPD) treatment. Objective This study aimed to assess the efficacy and cost-effectiveness of UMEC/VI versus tiotropium (TIO) 18 μg in symptomatic patients with COPD from the perspective of the Chinese National Healthcare System. Methods A simple analysis included three studies in the meta-analysis that compared UMEC/VI with TIO. A Markov model was developed to estimate the cost-effectiveness of UMEC/VI compared with TIO treatment in symptomatic patients with COPD. First, utilities, clinical efficacy, and adverse events obtained from the literature were utilized as model inputs. Costs were from Chinese average data, including local data. Costs were expressed in dollars based on 2020 prices. Then, the model outputs including drug costs, other medical costs, and total costs, and quality-adjusted life years (QALYs) were estimated. Costs and outcomes were discounted at a 5% annual rate. Furthermore, incremental cost-effective ratios (ICERs) were analyzed. Finally, the influences of changing parameters on the uncertainty of the results were assessed by means of one-way and probabilistic sensitivity analyses. Results This study revealed that UMEC/VI treatment had a higher rate of clinical efficacy in comparison with TIO, and the differences in the rate of adverse events between the two treatments were not significant. The results indicated that UMEC/VI was superior to TIO, which provided an increase in QALYs (0.002) and a total cost savings of $765.67 per patient over 3 years. In the base case, the ICER of UMEC/VI is -$397468.04/QALY compared with TIO, suggesting that UMEC/VI may be considered a dominant option over TIO. According to the Chinese medical system, the probability of UMEC/VI being cost-effective was 61.6% at a willingness-to-pay (WTP) of $31554/QALY. Sensitivity analyses confirmed that the results were robust. Conclusion UMEC/VI could be considered a cost-effective treatment compared with TIO in symptomatic COPD patients from the Chinese National Healthcare System perspective. These results may help decision-makers in China when making judgements on which treatments to administer.
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Maltais F, Vogelmeier CF, Kerwin EM, Bjermer LH, Jones PW, Boucot IH, Lipson DA, Tombs L, Compton C, Naya IP. Applying key learnings from the EMAX trial to clinical practice and future trial design in COPD. Respir Med 2022; 200:106918. [DOI: 10.1016/j.rmed.2022.106918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 10/18/2022]
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Fu Y, Chapman EJ, Boland AC, Bennett MI. Evidence-based management approaches for patients with severe chronic obstructive pulmonary disease (COPD): A practice review. Palliat Med 2022; 36:770-782. [PMID: 35311415 PMCID: PMC9087316 DOI: 10.1177/02692163221079697] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) face limited treatment options and inadequate access to palliative care. AIM To provide a pragmatic overview of clinical guidelines and produce evidence-based recommendations for severe COPD. Interventions for which there is inconsistent evidence to support their use and areas requiring further research were identified. DESIGN Practice review of guidelines supported by scoping review methodology to examine the evidence reporting the use of guideline-recommended interventions. DATA SOURCES An electronic search was undertaken in MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Database of Systematic Reviews, complemented by web searching for guidelines and publications providing primary evidence (July 2021). Guidelines published within the last 5 years and evidence in the last 10 years were included. RESULTS Severe COPD should be managed using a multidisciplinary approach with a holistic assessment. For stable patients, long-acting beta-agonist/long-acting muscarinic antagonist and pulmonary rehabilitation are recommended. Low dose opioids, self-management, handheld fan and nutritional support may provide small benefits, whereas routine corticosteroids should be avoided. For COPD exacerbations, systematic corticosteroids, non-invasive ventilation and exacerbation action plans are recommended. Short-acting inhaled beta-agonists and antibiotics may be considered but pulmonary rehabilitation should be avoided during hospitalisation. Long term oxygen therapy is only recommended for patients with chronic severe hypoxaemia. Short-acting anticholinergic inhalers, nebulised opioids, oral theophylline or telehealth are not recommended. CONCLUSIONS Recommended interventions by guidelines are not always supported by high-quality evidence. Further research is required on efficacy and safety of inhaled corticosteroids, antidepressants, benzodiazepines, mucolytics, relaxation and breathing exercises.
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Affiliation(s)
- Yu Fu
- Population Health Sciences Institute,
Newcastle University, Newcastle upon Tyne, UK
| | - Emma J Chapman
- Academic Unit of Palliative Care, Leeds
Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Alison C Boland
- Department of Respiratory Medicine, St
James’s University Hospital, Leeds, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds
Institute of Health Sciences, University of Leeds, Leeds, UK
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Maheswarappa H, Raman RA. Managing acute exacerbation of chronic obstructive pulmonary disease: What's new? INDIAN JOURNAL OF RESPIRATORY CARE 2022. [DOI: 10.4103/ijrc.ijrc_177_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Gong Y, Lv Y, Liu H, Zheng Q, Li L. Quantitative analysis of efficacy and safety of LABA/LAMA fixed-dose combinations in the treatment of stable COPD. Ther Adv Respir Dis 2022; 16:17534666211066068. [PMID: 35001708 PMCID: PMC8743917 DOI: 10.1177/17534666211066068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to quantitatively compare the efficacy and safety of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combinations (FDCs) for the treatment of stable chronic obstructive pulmonary disease (COPD), especially in terms of their loss of efficacy in lung function. METHODS Randomized controlled clinical trials of LABA/LAMA FDCs for the treatment of stable COPD were comprehensively searched for in public databases. Pharmacodynamic models were established to describe the time course of the primary outcome [trough forced expiratory volume in the first second (FEV1)]. Secondary outcomes [COPD exacerbations, St. George's Respiratory Questionnaire (SGRQ), Transition Dyspnoea Index (TDI), and rescue medication use] and safety outcomes [mortality, serious adverse events (SAEs), and withdrawals due to adverse events (AEs)] were also compared via a meta-analysis. RESULTS A total of 22 studies involving 16,486 participants were included in this study. The results showed that in terms of primary outcome (change from baseline in trough FEV1), the efficacy of vilanterol/umeclidinium was the highest, while the efficacy of formoterol/aclidinium was the lowest, with a maximum effect value (Emax) of 0.185 L [95% confidence interval (CI): 0.173-0.197 L] and 0.119 L (95% CI: 0.103-0.135 L), respectively. The efficacy of other drugs, such as formoterol/glycopyrronium, indacaterol/glycopyrronium, and olodaterol/tiotropium, were comparable, and their Emax values were 0.150-0.177 L. Except for vilanterol/umeclidinium, the other four LABA/LAMA FDCs showed a certain degree of loss of efficacy. Compared with the efficacy at 2 days, the trough FEV1 (L) relative to baseline at 24 weeks decreased by 0.029-0.041 L. In terms of secondary outcomes, the efficacy of different LABA/LAMA FDCs was similar in TDI and rescue medication use. However, formoterol/aclidinium was better in preventing the COPD exacerbations, while vilanterol/umeclidinium was the best in terms of SGRQ. In addition, different LABA/LAMA FDCs and placebo had similar safety outcomes. CONCLUSION The present findings may provide necessary quantitative information for COPD medication guidelines.
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Affiliation(s)
- Yiwen Gong
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yinghua Lv
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongxia Liu
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qingshan Zheng
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai 201203, China
| | - Lujin Li
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai 201203, China
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Abstract
There are many differences between men and women in risk factor vulnerability and impact, symptom development, presentation, clinical manifestations, and outcomes of chronic obstructive pulmonary disease (COPD). These differences have been inadequately explored, which is of particular concern in view of the delay in diagnosis and treatment that occurs for both men and women, and the need to use all therapies in a targeted and tailored way for best clinical gain and least harm. Women are generally underrepresented in randomized trials, as are non-tobacco-related phenotypes of COPD. We must garner the information available to better describe optimal treatment approaches.
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Affiliation(s)
- Christine Jenkins
- Respiratory Group, The George Institute for Global Health, Sydney, Level 5, 1 King Street, Newtown, New South Wales 2042 Australia; UNSW Medicine and Health, UNSW Sydney, NSW, Australia; Concord Clinical School, University of Sydney, NSW, Australia.
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Slade D, Ray R, Moretz C, Germain G, Laliberté F, Shen Q, Duh MS, Mahendran M, Hahn B. Time-to-first exacerbation, adherence, and medical costs among US patients receiving umeclidinium/vilanterol or tiotropium as initial maintenance therapy for chronic obstructive pulmonary disease: a retrospective cohort study. BMC Pulm Med 2021; 21:253. [PMID: 34332555 PMCID: PMC8325860 DOI: 10.1186/s12890-021-01612-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 07/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adherence to chronic obstructive pulmonary disease (COPD) maintenance medication is important for managing symptoms and exacerbation risk, and is associated with reduced mortality, hospitalizations, and costs. This study compared on-treatment exacerbations, medical costs, and medication adherence in patients with COPD initiating treatment with umeclidinium/vilanterol (UMEC/VI) or tiotropium (TIO). METHODS This retrospective matched cohort study selected patients from Optum's de-identified Clinformatics Data Mart database who initiated maintenance treatment with UMEC/VI or TIO between 01/01/2014 and 12/31/2017 (index date defined as the first dispensing). Eligible patients were ≥ 40 years of age and had ≥ 12 months continuous health plan coverage pre- and post-index; ≥ 1 medical claim for COPD pre-index or on the index date; no moderate/severe COPD-related exacerbations on the index date; no asthma diagnosis pre- or post-index; no maintenance medication fills containing inhaled corticosteroids, long-acting β2-agonists, or long-acting muscarinic antagonists pre-index or on the index date; and no fills for both UMEC/VI and TIO on the index date. Outcomes included time-to-first (Kaplan-Meier analysis) and rates of on-treatment COPD-related moderate/severe exacerbations, medication adherence (proportion of days covered [PDC] and proportion of adherent patients [PDC ≥ 0.8]), and COPD-related medical costs per patient per month (PPPM). Propensity score matching was used to adjust for potential confounders. RESULTS Each cohort included 3929 matched patients. Kaplan-Meier rates of on-treatment COPD-related exacerbations were similar between cohorts (hazard ratio at 12 months; overall: 0.93, moderate: 0.92, severe: 1.07; all p > 0.05). UMEC/VI versus TIO initiators had significantly higher adherence (mean PDC: 0.44 vs 0.37; p < 0.001; proportion with PDC ≥ 0.8: 22.0% vs 16.4%; p< 0.001) and significantly lower mean on-treatment COPD-related total medical costs ($867 vs $1095 PPPM; p = 0.028), driven by lower outpatient visit costs. CONCLUSIONS These findings provide valuable information for physicians considering UMEC/VI or TIO as initial maintenance therapy options for patients with COPD.
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Affiliation(s)
- David Slade
- US Medical Affairs, GSK, Research Triangle Park, NC, USA
| | - Riju Ray
- US Medical Affairs, GSK, Research Triangle Park, NC, USA
| | - Chad Moretz
- US Value Evidence & Outcomes, Medical Affairs, GSK, Research Triangle Park, NC, USA
| | | | | | - Qin Shen
- Global Value Evidence and Outcomes, GSK, Collegeville, PA, USA
| | | | | | - Beth Hahn
- US Value Evidence & Outcomes, Medical Affairs, GSK, Research Triangle Park, NC, USA.
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Singh D, Donohue JF, Boucot IH, Barnes NC, Compton C, Martinez FJ. Future concepts in bronchodilation for COPD: dual- versus monotherapy. Eur Respir Rev 2021; 30:30/160/210023. [PMID: 34415847 DOI: 10.1183/16000617.0023-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/06/2021] [Indexed: 11/05/2022] Open
Abstract
Most patients with COPD are recommended to initiate maintenance therapy with a single long-acting bronchodilator, such as a long-acting muscarinic antagonist or long-acting β2-agonist. However, many patients receiving mono-bronchodilation continue to experience high symptom burden, suggesting that patients are frequently not receiving optimal treatment. Treatment goals for COPD are often broad and not individually tailored, making initial treatment response assessments difficult. A personalised approach to initial maintenance therapy, based upon an individual's symptom burden and exacerbation risk, may be more appropriate.An alternative approach would be to maximise bronchodilation early in the disease course of all patients with COPD. Evidence suggests that dual bronchodilation has greater and consistent efficacy for lung function and symptoms than mono-bronchodilation, whilst potentially reducing the risk of exacerbations and disease deterioration, with a similar safety profile to mono-bronchodilators. Improvements in lung function and symptoms between dual- and mono-bronchodilation have also been demonstrated in maintenance-naïve patients, who are most likely to resemble those at first presentation in a clinical setting. Despite promising results, there are several evidence gaps that need to be addressed to allow decision makers to evaluate the merits of a widespread earlier introduction of dual bronchodilation.
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Affiliation(s)
- Dave Singh
- Centre for Respiratory Medicine and Allergy, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, School of Medicine, Chapel Hill, NC, USA
| | | | - Neil C Barnes
- Global Specialty & Primary Care, GSK, Brentford, UK.,Weill Cornell Medical College, New York, NY, USA
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Dual LABA/LAMA Therapy versus LABA or LAMA Monotherapy for Chronic Obstructive Pulmonary Disease. A Systematic Review and Meta-analysis in Support of the American Thoracic Society Clinical Practice Guideline. Ann Am Thorac Soc 2021; 17:1133-1143. [PMID: 32530702 DOI: 10.1513/annalsats.201912-915oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: There is uncertainty on the optimal first-line therapy for symptomatic chronic obstructive pulmonary disease (COPD). Long-acting β2-receptor agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) have long been mainstays of treatment, though it is still not clear if dual therapy with LABA/LAMA is superior to monotherapy for symptomatic COPD.Objectives: To clarify the evidence landscape, we conducted a systematic review to answer the following question: in patients with COPD who complain of dyspnea and/or exercise intolerance, is LABA/LAMA combination therapy more effective and equally safe compared with LABA or LAMA monotherapy?Methods: A search of Medline, EMBASE, and the Cochrane Library databases was conducted by a medical librarian for randomized controlled trials enrolling patients with COPD who complain of dyspnea and/or exercise intolerance that compare LABA/LAMA combination therapy to LABA or LAMA monotherapy. A systematic approach was used to screen, abstract, and critically appraise the emerging study evidence. The Grading of Recommendations Assessment, Development, and Evaluation method was applied to rate the certainty and quality of the evidence.Results: A total of 24 studies were eligible for inclusion (n = 45,441). Pairwise random-effects meta-analysis revealed reductions in hospital admissions (11% reduction; P < 0.01) and acute exacerbations of COPD (20% reduction; P < 0.002), all in favor of LABA/LAMA dual therapy. Although there is reduced dyspnea (0.10 standardized mean difference; P < 0.001) and improved health-related quality of life (-0.13 standardized mean difference; P < 0.001), both values did not meet a clinical meaningful difference threshold. LABA/LAMA combination therapy showed no difference in treatment-emergent adverse effects (risk ratio, 0.99; P = 0.34) when compared with either LAMA or LABA monotherapy.Conclusions: Based on the reviewed evidence, in patients with symptomatic COPD who complain of dyspnea and/or exercise intolerance, dual LABA/LAMA therapy is superior to either LABA or LAMA monotherapy based on the reduced risk of exacerbations and hospitalizations.
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Cheng SL. Comparison of Effectiveness Using Different Dual Bronchodilator Agents in Chronic Obstructive Pulmonary Disease Treatment. J Clin Med 2021; 10:jcm10122649. [PMID: 34208599 PMCID: PMC8235085 DOI: 10.3390/jcm10122649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022] Open
Abstract
The effectiveness and safety of fixed dual long-acting bronchodilators for chronic obstructive pulmonary disease (COPD) patients have been well established; however, there is a paucity of clinical effectiveness comparison in patients with COPD treatment. The aim of the current study was to compare the effectiveness of three once-daily dual bronchodilator agents in patients with COPD. Patients with diagnosed COPD and treated with a long-acting beta-agonist (LABA) + long-acting muscarinic antagonist (LAMA) fixed-dose combination therapy (UME/VIL (umeclidinium and vilanterol inhalation powder), IND/GLY (indacaterol and glycopyrronium), and TIO/OLO (tiotropium and olodaterol)) were enrolled in this retrospective study over a period of 12 months. Effectiveness assessments were evaluated using a COPD assessment test (CAT) and lung function parameters. Besides, times for acute exacerbation were also assessed. The enrolled patients’ number was 177 in IND/GLY, 176 in UME/VIL and 183 in TIO/OLO. Lung function measurements with FEV1 had significantly improved for patients using TIO/OLO (98.7 mL) compared to those of IND/GLY (65.2 mL) and UME/VIL (64.4 mL) (p < 0.001). CAT scores were also significantly decreased in patients treated with TIO/OLO (CAT down 5.6) than those with IND/GLY (3.8) and UME/VIL (3.9) (p = 0.03). Acute exacerbation was also reduced in patients using TIO/OLO (4.9%) compared with those using IND/GLY (10.2%) and UME/VIL (11.9%) (p = 0.01). Significant improvement in pulmonary function, symptoms were demonstrated after 12 months of LABA/LAMA fixed-dose combination therapy with three different treatment options. TIO/OLO demonstrated higher therapeutic effects compared with UME/VIL or IND/GLY. Determining clinical relevance will require a well-designed randomized controlled trial.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, New-Taipei City 22060, Taiwan; ; Tel.: +886-2-8966-7000 (ext. 2160); Fax: +886-2-7738-0708
- Department of Chemical Engineering and Materials Science, Yuan-Ze University, Taoyuan City 320315, Taiwan
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Slade D, Ray R, Moretz C, Germain G, Laliberté F, Shen Q, Duh MS, MacKnight SD, Hahn B. Hospital Admission and Readmission Among US Patients Receiving Umeclidinium/Vilanterol or Tiotropium as Initial Maintenance Therapy for Chronic Obstructive Pulmonary Disease. Pulm Ther 2021; 7:203-219. [PMID: 33728597 PMCID: PMC8137777 DOI: 10.1007/s41030-021-00151-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/15/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations are at risk of further readmissions, increased treatment costs, and excess mortality. This study evaluated inpatient admissions and readmissions in patients receiving initial maintenance therapy with umeclidinium/vilanterol (UMEC/VI) versus tiotropium (TIO). METHODS This retrospective, matched cohort study identified patients with COPD who initiated maintenance therapy with UMEC/VI or TIO from Optum's de-identified Clinformatics Data Mart database between January 1, 2013, and December 31, 2018 (index date defined as earliest dispensing). Eligibility criteria included: ≥ 1 medical claim for COPD pre-index or on the index date; ≥ 12 months of continuous eligibility pre-index; age ≥ 40 years at index; no pre- or post-index asthma diagnosis; and no pre-index claims for medications containing inhaled corticosteroids, long-acting β2-agonists, or long-acting muscarinic antagonists. Outcomes included time to first on-treatment COPD-related inpatient admission, rate of on-treatment COPD-related admissions, and rate of all-cause and COPD-related readmissions within 30 and 90 days. Propensity score matching was used to adjust for potential confounders. RESULTS Matched UMEC/VI and TIO cohorts each included 7997 patients and were balanced on baseline characteristics (mean age 70.9 years; female 47.1-47.6%). Over 12 months, patients initiating UMEC/VI had significantly reduced risk (hazard ratio [95% CI]: 0.87 [0.79, 0.96]; p = 0.006) and rates (rate ratio [95% CI]: 0.80 [0.72, 0.92]; p = 0.008) of COPD-related inpatient admissions compared with TIO. While all-cause readmission rates were similar between treatment cohorts, readmission rates among patients with an initial admission length of stay of 1-3 days were numerically lower for UMEC/VI versus TIO (30-day readmissions: 10.5% vs. 12.4%; 90-day readmissions: 15.5% vs. 19.8%). Similar patterns were observed for COPD-related readmissions. CONCLUSIONS These findings highlight the real-world benefits of dual therapy with UMEC/VI versus TIO in reducing inpatient admissions and readmissions in patients with COPD, which may translate to lower healthcare costs.
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Affiliation(s)
- David Slade
- US Medical Affairs, GSK, Research Triangle Park, NC, USA
| | - Riju Ray
- US Medical Affairs, GSK, Research Triangle Park, NC, USA
| | - Chad Moretz
- US Value Evidence and Outcomes, GSK, Research Triangle Park, NC, USA
| | | | | | | | | | | | - Beth Hahn
- US Value Evidence and Outcomes, GSK, Research Triangle Park, NC, USA.
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Kalhan R, Slade D, Ray R, Moretz C, Germain G, Laliberté F, Shen Q, Duh MS, MacKnight SD, Hahn B. Umeclidinium/Vilanterol Compared with Fluticasone Propionate/Salmeterol, Budesonide/Formoterol, and Tiotropium as Initial Maintenance Therapy in Patients with COPD Who Have High Costs and Comorbidities. Int J Chron Obstruct Pulmon Dis 2021; 16:1149-1161. [PMID: 33911860 PMCID: PMC8075186 DOI: 10.2147/copd.s298032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background Comorbidities in patients with chronic obstructive pulmonary disease (COPD) are associated with increased medical costs and risk of exacerbations. This study compared COPD-related medical costs and exacerbations in high-cost, high-comorbidity patients with COPD receiving initial maintenance treatment (IMT) with umeclidinium/vilanterol (UMEC/VI) versus fluticasone propionate/salmeterol (FP/SAL), budesonide/formoterol (B/F), or tiotropium (TIO). Methods This retrospective, matched cohort study identified patients from Optum’s de-identified Clinformatics Data Mart database who initiated UMEC/VI, FP/SAL, B/F, or TIO between January 1, 2014 and December 31, 2018 (index date defined as date of the first fill). Eligibility criteria included age ≥40 years at index, ≥1 pre-index COPD diagnosis, no pre-index asthma diagnosis, 12 months of continuous insurance coverage pre-index, and high pre-index costs (≥80th percentile of IMT population) and comorbidities (Quan-Charlson comorbidity index ≥3). Propensity score matching was used to control for potential confounders. On-treatment COPD-related medical costs (primary endpoint) and exacerbations were evaluated. Results Matched cohorts were well balanced on baseline characteristics (UMEC/VI vs FP/SAL: n=1194 each; UMEC/VI vs B/F: n=1441 each; UMEC/VI vs TIO: n=1277 each). Patients receiving UMEC/VI had significantly lower COPD-related medical costs versus FP/SAL (difference: $6587 per patient per year; P=0.048), and numerically lower costs versus B/F and TIO. Patients initiating UMEC/VI had significantly lower risk of COPD-related severe exacerbation versus FP/SAL (hazard ratio [95% CI]: 0.78 [0.62, 0.98]; P=0.032), B/F (0.77 [0.63, 0.95]; P=0.016), and TIO (0.79 [0.64, 0.98]; P=0.028). The rate of COPD-related severe exacerbations was significantly lower with UMEC/VI versus FP/SAL (rate ratio [95% CI]: 0.73 [0.59, 0.91]; P=0.008) and B/F (0.73 [0.59, 0.93]; P=0.012), and numerically lower versus TIO (0.83 [0.68, 1.04]; P=0.080). Conclusion These findings suggest that high-cost, high-comorbidity patients with COPD receiving UMEC/VI compared with FP/SAL, B/F, and TIO as IMT may have lower medical costs and exacerbation risk.
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Affiliation(s)
- Ravi Kalhan
- Asthma and COPD Program, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Slade
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Riju Ray
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Chad Moretz
- US Value Evidence and Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA
| | | | | | - Qin Shen
- US Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA
| | | | | | - Beth Hahn
- US Value Evidence and Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA
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Larsson K, Ekberg-Jansson A, Stridsman C, Hanno M, Vanfleteren LEGW. Adherence to Treatment Recommendations for Chronic Obstructive Pulmonary Disease - Results from the Swedish National Airway Register. Int J Chron Obstruct Pulmon Dis 2021; 16:909-918. [PMID: 33854309 PMCID: PMC8039432 DOI: 10.2147/copd.s300299] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Swedish guidelines adhere to the international GOLD document regarding management of chronic obstructive pulmonary disease (COPD). Based on data from the Swedish National Airway Register (SNAR) the aim was to evaluate adherence to guidelines of pharmacological treatment of COPD in Swedish primary and secondary care. METHODS During a period of 18 months, data on symptoms (CAT, mMRC), lung function, exacerbation history and pharmacological treatment from 15,595 COPD patients from 853 primary care and 125 secondary care clinics were collected from SNAR. Patients with a co-diagnosis of asthma were excluded. Patients were divided into four treatment groups: no pharmacological treatment, short-acting bronchodilators alone, long-acting bronchodilators alone and ICS alone or in combination with bronchodilators. RESULTS Of the patients, 29% were in GOLD group A, 58% in group B, 2% in group C and 11% in group D. CAT score was ≥10 and mMRC score was below 2 in 30.9% of the patients and mMRC score was ≥2 and CAT score <10 in 4.2% of the patients. In 61.4% of the patients, no exacerbation was registered during the last year. Long-acting bronchodilators were prescribed for 78% and ICS for 46% of all patients. In groups A, B, C and D, respectively, 21%, 11%, 11% and 5% did not receive any inhaler therapy; 67%, 81%, 81% and 90% received long-acting bronchodilators; 33%, 46%, 55% and 71% received any ICS containing therapy and 19%, 34%, 39% and 61% received triple therapy. DISCUSSION Data from the SNAR indicate that only a minority of COPD patients were untreated. There was a liberal use of ICS containing drug combinations in subjects who do not have an indication for ICS. A considerable proportion of subjects at high risk of exacerbations did not receive ICS treatment.
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Affiliation(s)
- Kjell Larsson
- Integrative Toxicology, National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ann Ekberg-Jansson
- Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Caroline Stridsman
- Department of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | | | - Lowie E G W Vanfleteren
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, 413 45, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 413 45, Sweden
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Role of Airway Smooth Muscle in Inflammation Related to Asthma and COPD. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1303:139-172. [PMID: 33788192 DOI: 10.1007/978-3-030-63046-1_9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Airway smooth muscle contributes to both contractility and inflammation in the pathophysiology of asthma and COPD. Airway smooth muscle cells can change the degree of a variety of functions, including contraction, proliferation, migration, and the secretion of inflammatory mediators (phenotype plasticity). Airflow limitation, airway hyperresponsiveness, β2-adrenergic desensitization, and airway remodeling, which are fundamental characteristic features of these diseases, are caused by phenotype changes in airway smooth muscle cells. Alterations between contractile and hyper-contractile, synthetic/proliferative phenotypes result from Ca2+ dynamics and Ca2+ sensitization. Modulation of Ca2+ dynamics through the large-conductance Ca2+-activated K+ channel/L-type voltage-dependent Ca2+ channel linkage and of Ca2+ sensitization through the RhoA/Rho-kinase pathway contributes not only to alterations in the contractile phenotype involved in airflow limitation, airway hyperresponsiveness, and β2-adrenergic desensitization but also to alteration of the synthetic/proliferative phenotype involved in airway remodeling. These Ca2+ signal pathways are also associated with synergistic effects due to allosteric modulation between β2-adrenergic agonists and muscarinic antagonists. Therefore, airway smooth muscle may be a target tissue in the therapy for these diseases. Moreover, the phenotype changing in airway smooth muscle cells with focuses on Ca2+ signaling may provide novel strategies for research and development of effective remedies against both bronchoconstriction and inflammation.
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Bourbeau J, Bafadhel M, Barnes NC, Compton C, Di Boscio V, Lipson DA, Jones PW, Martin N, Weiss G, Halpin DMG. Benefit/Risk Profile of Single-Inhaler Triple Therapy in COPD. Int J Chron Obstruct Pulmon Dis 2021; 16:499-517. [PMID: 33688176 PMCID: PMC7935340 DOI: 10.2147/copd.s291967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/07/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with major healthcare and socioeconomic burdens. International consortia recommend a personalized approach to treatment and management that aims to reduce both symptom burden and the risk of exacerbations. Recent clinical trials have investigated single-inhaler triple therapy (SITT) with a long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA), and inhaled corticosteroid (ICS) for patients with symptomatic COPD. Here, we review evidence from randomized controlled trials showing the benefits of SITT and weigh these against the reported risk of pneumonia with ICS use. We highlight the challenges associated with cross-trial comparisons of benefit/risk, discuss blood eosinophils as a marker of ICS responsiveness, and summarize current treatment recommendations and the position of SITT in the management of COPD, including potential advantages in terms of improving patient adherence. Evidence from trials of SITT versus dual therapies in symptomatic patients with moderate to very severe airflow limitation and increased risk of exacerbations shows benefits in lung function and patient-reported outcomes. Moreover, the key benefits reported with SITT are significant reductions in exacerbations and hospitalizations, with data also suggesting reduced all-cause mortality. These benefits outweigh the ICS-class effect of higher incidence of study-reported pneumonia compared with LAMA/LABA. Important differences in trial design, baseline population characteristics, such as exacerbation history, and assessment of outcomes, have significant implications for interpreting data from cross-trial comparisons. Current understanding interprets the blood eosinophil count as a continuum that can help predict response to ICS and has utility alongside other clinical factors to aid treatment decision-making. We conclude that treatment decisions in COPD should be guided by an approach that considers benefit versus risk, with early optimization of treatment essential for maximizing long-term benefits and patient outcomes.
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Affiliation(s)
- Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mona Bafadhel
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Neil C Barnes
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- William Harvey Institute, Bart’s and the London School of Medicine and Dentistry, London, UK
| | - Chris Compton
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | | | - David A Lipson
- Clinical Sciences, GlaxoSmithKline, Collegeville, PA, USA
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul W Jones
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- Institute of Infection and Immunity, St George’s, University of London, London, UK
| | - Neil Martin
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- University of Leicester, Leicester, UK
| | - Gudrun Weiss
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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Kang J, Lee JS, Lee SW, Lee JB, Oh YM. Dual versus monotherapy with bronchodilators in GOLD group B COPD patients according to baseline FEV 1 level: a patient-level pooled analysis of phase-3 randomized clinical trials. Respir Res 2021; 22:55. [PMID: 33579288 PMCID: PMC7881547 DOI: 10.1186/s12931-021-01648-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Which patients should receive dual therapy as initial treatment for chronic obstructive pulmonary disease (COPD) is only loosely defined. We evaluated if a lower forced expiratory volume in 1 s (FEV1) identifies a population more likely to benefit from dual therapy than monotherapy among group B COPD patients in whom Global initiative for Chronic Obstructive Pulmonary Disease (GOLD) recommends monotherapy as initial treatment. Methods This was a patient-level pooled analysis of phase-3 randomized controlled trials involving dual bronchodilators. Study patients were classified into two groups based on the FEV1 of 50% of the predicted value (GOLD I/II versus GOLD III/IV). We evaluated the efficacy of dual versus monotherapy (long-acting beta-2 agonist [LABA] or long-acting muscarinic antagonist [LAMA]) between these two groups in the following outcomes: changes in trough FEV1, the St. George’s Respiratory Questionnaire (SGRQ) score, the proportion of SGRQ responders, time to first exacerbation, and risk of adverse events. Results A total of 14,449 group B patients from 12 studies were divided into GOLD III/IV (n = 8043) or GOLD I/II group (n = 6406). In the GOLD III/IV group, dual therapy was significantly more effective in improving FEV1, reducing SGRQ scores, and achieving a higher proportion of SGRQ responders compared with either LABA or LAMA. Dual therapy also showed a significantly longer time to first exacerbation compared with LABA in the GOLD III/IV group. In contrast, in the GOLD I/II group, the benefits of dual therapy over monotherapy were less consistent. Although dual therapy resulted in significantly higher FEV1 than either LABA or LAMA, it did not show significant differences in the SGRQ score and proportion of SGRQ responders as compared with LABA. The time to first exacerbation was also not significantly different between dual therapy and either LABA or LAMA in the GOLD I/II group. Conclusions Dual therapy demonstrated benefits over monotherapy more consistently in patients with lower FEV1 than those with higher FEV1.
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Affiliation(s)
- Jieun Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Seoul, Republic of Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Seoul, Republic of Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, 88 Olympic-ro 43-gil, Seoul, Republic of Korea.
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Seoul, Republic of Korea.
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Lipari M, Kale-Pradhan PB, Wilhelm SM. Dual– Versus Mono–Bronchodilator Therapy in Moderate to Severe COPD: A Meta-analysis. Ann Pharmacother 2020; 54:1232-1242. [DOI: 10.1177/1060028020932134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Chronic obstructive pulmonary disease (COPD) guidelines recommend both long-acting and dual bronchodilator therapy. It is unclear if there are differences in efficacy and safety. Objective: This meta-analysis evaluates the efficacy of dual therapy with long-acting β-agonist (LABA) + long acting muscarinic antagonist (LAMA) compared with monotherapy with LAMA for COPD. Methods: We searched PubMed, CINAHL, and Web of Science databases from inception through March 2020 to identify English-language, prospective randomized controlled trials (RCTs) that compared dual therapy with monotherapy in adult patients with COPD. Risk of bias was assessed using the Jadad score. Overall analysis was performed using Review Manager 5.3. Treatment effect was determined with the random-effects model using the Mantel-Haenszel method and was reported as mean difference (MD) with 95% CI. Results: A total of 18 RCTs were included (n = 6086; median Jadad score 5/5) that compared LAMA + LABA with LAMA. There was a greater improvement in forced expiratory volume at 1 s (FEV1) with dual therapy compared with LAMA: MD = 0.08; 95% CI = [0.05, 0.11]. There was no difference in St George Respiratory Questionnaire (SGRQ) scores between groups: OR = −0.85; 95% CI = [−1.83, 0.13]. There were no differences in overall adverse events (OR = 1.00; 95% CI = 0.92, 1.09), serious adverse events (OR = 1.01; 95% CI = 0.86, 1.18), or cardiovascular events (OR = 0.88; 95% CI = 0.58, 1.34). Conclusion and Relevance: Dual therapy improves FEV1 and is as safe as LAMA. Dual therapy does not improve SGRQ scores more than LAMA.
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Affiliation(s)
- Melissa Lipari
- Wayne State University, Detroit, MI, USA
- Ascension St. John Hospital, Detroit, MI, USA
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Papaioannou AI, Loukides S, Bakakos P, Kosmas EN, Rovina N, Steiropoulos P, Fouka E, Hillas G, Patentalakis G, Kouvela M, Tzanakis N. Dual Bronchodilator in the Era of Triple Therapy. Int J Chron Obstruct Pulmon Dis 2020; 15:2695-2705. [PMID: 33149567 PMCID: PMC7604249 DOI: 10.2147/copd.s273987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/23/2020] [Indexed: 01/18/2023] Open
Abstract
Pharmacological medications used for the treatment of COPD patients have increased significantly. Long-acting bronchodilators have been recognized as the mainstay of the treatment of stable COPD, while ICS are usually added in patients with COPD who experience exacerbations, despite bronchodilator treatment. In the latest years, several studies have been published showing the beneficial effect of adding ICS on dual bronchodilation in patients suffering from more severe disease comparing triple therapy with several therapeutic regiments including dual bronchodilation and providing a message that this triple therapy might be more appropriate for COPD patients. However, not all COPD patients have a desirable response to ICS treatment while long-term ICS use in COPD is associated with several side effects. In this report, we aimed to provide a review of the current knowledge on the importance of dual bronchodilation on COPD patients and to compare its use with triple therapy, by covering a wide spectrum of topics. Finally, we propose an algorithm on performing treatment step up from dual bronchodilation to triple therapy and step down from triple to double bronchodilation considering the current evidence.
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Affiliation(s)
- Andriana I Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Petros Bakakos
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | | | - Nikoletta Rovina
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangellia Fouka
- Respiratory Medicine Department, Aristotle University of Thessaloniki, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Georgios Hillas
- 5th Respiratory Medicine Department, Sotiria Chest Hospital, Athens, Greece
| | | | - Marousa Kouvela
- 3rd Department of Medicine, Athens Medical School, Athens, Greece
| | - Nikos Tzanakis
- Department of Thoracic Medicine, Faculty of Medicine, University of Crete, Crete, Greece
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Anzueto A, Kaplan A. Dual bronchodilators in chronic obstructive pulmonary disease: Evidence from randomized controlled trials and real-world studies. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Takahashi K, Uchida M, Kato G, Takamori A, Kinoshita T, Yoshida M, Tajiri R, Kojima K, Inoue H, Kobayashi H, Sadamatsu H, Tashiro H, Tanaka M, Hayashi S, Kawaguchi A, Kimura S, Sueoka-Aragane N, Kawayama T. First-Line Treatment with Tiotropium/Olodaterol Improves Physical Activity in Patients with Treatment-Naïve Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:2115-2126. [PMID: 32982204 PMCID: PMC7501469 DOI: 10.2147/copd.s268905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/18/2020] [Indexed: 11/23/2022] Open
Abstract
Background Comparative effects on physical activity of mono and dual bronchodilators remain unclear in patients with treatment-naïve chronic obstructive pulmonary disease (COPD). We sought to compare the changes in physical activity before and after tiotropium and tiotropium/olodaterol treatment in treatment-naïve COPD patients. Methods A prospective, multicenter, randomized, open-labeled, and parallel interventional study was conducted. Eighty Japanese patients with treatment-naïve COPD were randomized to receive either tiotropium or tiotropium/olodaterol treatment for 12 weeks. Spirometry and dyspnea index were assessed, and COPD assessment test (CAT) and the 6-minute walk distance (6MWD) were conducted before and after treatment. Evaluation of physical activity was assessed by a triaxle accelerometer over a 2-week period before and after treatment. Results There were no differences in the mean age (69.8 vs 70.4 years), body mass index (BMI) (22.5 vs 22.6 kg/m2) and mean % forced expiratory volume in 1 second (%FEV1) at baseline (61.5 vs 62.6%) between the two groups. Changes in FEV1 (mean±standard error, 242.8±28.8 mL) and transient dyspnea index (TDI) (2.4±0.3 points) before and after tiotropium/olodaterol treatment were greater than with tiotropium treatment (104.1±31.9 mL, p<0.01 and 1.5±0.3, p=0.02, respectively). Changes in the duration of physical activity with 1.0–1.5 metabolic equivalents (METs) estimated in the sedentary position following tiotropium/olodaterol treatment (−38.7±14.7 min) tended to be reduced more than with tiotropium treatment (−4.6±10.6 min) (p=0.06), although those with ≥2.0 METs numerically increased with both treatments (+10.8±7.6 min for tiotropium/olodaterol vs +8.3±7.6 min for tiotropium, p=0.82). Tiotropium/olodaterol treatment reduced the duration of physical activity with 1.0–1.5 METs (regression coefficient, −43.6 [95% CI −84.1, −3.1], p=0.04) in a multiple regression model adjusted for cofounding factors such as age, FEV1, total CAT scores, 6MWD, and TDI. Conclusion This is the first study to report the impact of dual bronchodilator on physical activity in treatment-naïve COPD patients of Japanese with low BMI.
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Affiliation(s)
- Koichiro Takahashi
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Masaru Uchida
- Division of Internal Medicine, Japan Community Health Care Organization Saga Central Hospital, Saga, Japan
| | - Go Kato
- Division of Respiratory Medicine, Saga Prefectural Medical Center Koseikan, Saga, Japan
| | - Ayako Takamori
- Clinical Research Center, Saga University Hospital, Faculty of Medicine, Saga University, Saga, Japan
| | - Takashi Kinoshita
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Makoto Yoshida
- Division of Respiratory Medicine, National Hospital Organization Fukuoka Hospital, Fukuoka, Japan
| | - Ryo Tajiri
- Clinical Research Center, Saga University Hospital, Faculty of Medicine, Saga University, Saga, Japan
| | - Keisuke Kojima
- Division of Internal Medicine, Imari Arita Kyouritsu Hospital, Saga, Japan
| | - Hiroshi Inoue
- Division of Internal Medicine, Karatsu Red Cross Hospital, Saga, Japan
| | - Hiromi Kobayashi
- Division of Respiratory Medicine, National Hospital Organization East Saga Hospital, Saga, Japan
| | - Hironori Sadamatsu
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroki Tashiro
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Masahide Tanaka
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shinichiro Hayashi
- Division of Internal Medicine, Kouhoukai Takagi Hospital, Fukuoka, Japan
| | - Atsushi Kawaguchi
- Clinical Research Center, Saga University Hospital, Faculty of Medicine, Saga University, Saga, Japan.,Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Naoko Sueoka-Aragane
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
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Müllerová H, Dransfield MT, Thomashow B, Jones PW, Rennard S, Karlsson N, Fageras M, Metzdorf N, Petruzzelli S, Rommes J, Sciurba FC, Tabberer M, Merrill D, Tal-Singer R. Clinical Development and Research Applications of the Chronic Obstructive Pulmonary Disease Assessment Test. Am J Respir Crit Care Med 2020; 201:1058-1067. [PMID: 31815521 DOI: 10.1164/rccm.201907-1369pp] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Hana Müllerová
- Value Evidence and Outcomes, Global Medical R&D, GlaxoSmithKline, Uxbridge, United Kingdom
| | - Mark T Dransfield
- Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Paul W Jones
- Value Evidence and Outcomes, Global Medical R&D, GlaxoSmithKline, Uxbridge, United Kingdom
| | - Stephen Rennard
- University of Nebraska, Omaha, Nebraska.,BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Malin Fageras
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | | | | | - Frank C Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Maggie Tabberer
- Value Evidence and Outcomes, Global Medical R&D, GlaxoSmithKline, Uxbridge, United Kingdom
| | | | - Ruth Tal-Singer
- Value Evidence and Outcomes, Medical Innovation, Global Medical R&D, GlaxoSmithKline, Collegeville, Pennsylvania
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26
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Nici L, Mammen MJ, Charbek E, Alexander PE, Au DH, Boyd CM, Criner GJ, Donaldson GC, Dreher M, Fan VS, Gershon AS, Han MK, Krishnan JA, Martinez FJ, Meek PM, Morgan M, Polkey MI, Puhan MA, Sadatsafavi M, Sin DD, Washko GR, Wedzicha JA, Aaron SD. Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e56-e69. [PMID: 32283960 PMCID: PMC7193862 DOI: 10.1164/rccm.202003-0625st] [Citation(s) in RCA: 191] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society. Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy. Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.
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27
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Shin SH, Kang N, Cho J, Choi Y, Cho HK, Choi HS, Kim H, Lim JH, Park HY. Stable Clinical Course of Chronic Obstructive Pulmonary Disease Patients in the Era of Double Bronchodilator Therapy: A Single Referral Center Experience. J Clin Med 2020; 9:E2547. [PMID: 32781649 PMCID: PMC7465249 DOI: 10.3390/jcm9082547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 11/16/2022] Open
Abstract
Despite clinical benefits of long-acting muscarinic antagonist (LAMA)/long-acting beta2-agonist (LABA) double bronchodilator therapy, there has been limited evidence for treatment change from LAMA/LABA to inhaled corticosteroid (ICS)-containing therapy. This study aimed to assess the rate of ICS-containing therapy from LAMA/LABA and investigate the factors associated with ICS addition. Between October 2015 and March 2019, consecutive patients prescribed with a LAMA/LABA fixed-dose combinations (FDCs) therapy without ICS were retrospectively identified from a single-referral hospital. The primary outcome was addition of ICS. During LAMA/LABA FDCs therapy (median, 12.4 months), 47 (17.7%) out of 266 patients had ICS addition. Most patients maintained bronchodilators without addition of ICS at 12 (86.5%) or 24 (76.8%) months. Patients with dyspnea (mMRC ≥ 2) at baseline, previous ICS use, and exacerbation in the previous year were at a higher risk of ICS addition. Especially, exacerbation in the previous year and dyspnea were associated with the development of frequent exacerbations during LAMA/LABA FDCs therapy, which might have led to ICS addition. Double bronchodilator therapy could be well-maintained in stable COPD patients. However, patients with exacerbation in the previous year, dyspnea, and previous ICS use should be closely approached and monitored with initiation of LAMA/LABA FDCs therapy without ICS.
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Affiliation(s)
- Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (S.H.S.); (N.K.); (Y.C.); (H.K.C.); (H.K.)
| | - Noeul Kang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (S.H.S.); (N.K.); (Y.C.); (H.K.C.); (H.K.)
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul 06351, Korea;
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul 06355, Korea
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MA 21287, USA
| | - Yeonseok Choi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (S.H.S.); (N.K.); (Y.C.); (H.K.C.); (H.K.)
| | - Hyun Kyu Cho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (S.H.S.); (N.K.); (Y.C.); (H.K.C.); (H.K.)
| | - Hye Sook Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University Hospital, Seoul 02447, Korea;
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (S.H.S.); (N.K.); (Y.C.); (H.K.C.); (H.K.)
| | - Jun Hyeok Lim
- Division of Pulmonology, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon 22332, Korea;
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (S.H.S.); (N.K.); (Y.C.); (H.K.C.); (H.K.)
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28
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Chen CY, Chen WC, Huang CH, Hsiang YP, Sheu CC, Chen YC, Lin MC, Chu KA, Lee CH, Wei YF. LABA/LAMA fixed-dose combinations versus LAMA monotherapy in the prevention of COPD exacerbations: a systematic review and meta-analysis. Ther Adv Respir Dis 2020; 14:1753466620937194. [PMID: 32643547 PMCID: PMC7350046 DOI: 10.1177/1753466620937194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Long-acting muscarinic antagonist (LAMA) monotherapy is recommended for chronic obstructive pulmonary disease (COPD) patients with high risk of exacerbations. It is unclear whether long-acting β2-agonist (LABA)/LAMA fixed-dose combinations (FDCs) are more effective than LAMAs alone in preventing exacerbations. The aim of this study was to systematically review the literature to investigate whether LABA/LAMA FDCs are more effective than LAMA monotherapy in preventing exacerbations. Methods: We searched several databases and manufacturers’ websites to identify relevant randomized clinical trials comparing LABA/LAMA FDC treatment with LAMAs alone ⩾24 weeks. Outcomes of interest were time to first exacerbation and rates of moderate to severe, severe and all exacerbations. Results: We included 10 trials in 9 articles from 2013 to 2018 with a total of 19,369 patients for analysis in this study. Compared with LAMA monotherapy, LABA/LAMA FDCs demonstrated similar efficacy in terms of time to first exacerbation [hazard ratio, 0.96; 95% confidence interval (CI) 0.79–1.18; p = 0.71], moderate to severe exacerbations [risk ratio (RR), 0.96; 95% CI 0.90–1.03; p = 0.28], severe exacerbations (RR, 0.92; 95% CI 0.81–1.03; p = 0.15), and a marginal superiority in terms of all exacerbations (RR, 0.92; 95% CI 0.86–1.00; p = 0.04). The incidence of all exacerbation events was lower in the LABA/LAMA FDC group for the COPD patients with a history of previous exacerbations and those with a longer treatment period (52–64 weeks). Conclusion: This study provides evidence that LABA/LAMA FDCs are marginally superior in the prevention of all exacerbations compared with LAMA monotherapy in patients with COPD. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Ching-Yi Chen
- Division of Chest Medicine, Department of Internal Medicine, E-Da Hospital, Kaohsiung
| | - Wang-Chun Chen
- Department of Pharmacy, E-Da Hospital, I-Shou University, Kaohsiung
| | - Chi-Hsien Huang
- Department of Family Medicine, E-Da Hospital, I-Shou University, Kaohsiung.,Department of Community Healthcare & Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yi-Ping Hsiang
- Department of Pharmacy, E-Da Hospital, I-Shou University, Kaohsiung
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung.,Department of Internal Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Yung-Che Chen
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Kuo-An Chu
- Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Cheng-Hung Lee
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan
| | - Yu-Feng Wei
- Department of Internal Medicine, E-Da Hospital, I-Shou University, No. 1, Yida Road, Jiao-su Village, Yan-chao District, Kaohsiung 824.,School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung
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29
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Singh D, Criner GJ, Naya I, Jones PW, Tombs L, Lipson DA, Han MK. Measuring disease activity in COPD: is clinically important deterioration the answer? Respir Res 2020; 21:134. [PMID: 32487202 PMCID: PMC7265253 DOI: 10.1186/s12931-020-01387-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
Given the heterogeneity of chronic obstructive pulmonary disease (COPD), personalized clinical management is key to optimizing patient outcomes. Important treatment goals include minimizing disease activity and preventing disease progression; however, quantification of these components remains a challenge. Growing evidence suggests that decline over time in forced expiratory volume in 1 s (FEV1), traditionally the key marker of disease progression, may not be sufficient to fully determine deterioration across COPD populations. In addition, there is a lack of evidence showing that currently available multidimensional COPD indexes improve clinical decision-making, treatment, or patient outcomes. The composite clinically important deterioration (CID) endpoint was developed to assess disease worsening by detecting early deteriorations in lung function (measured by FEV1), health status (assessed by the St George's Respiratory Questionnaire), and the presence of exacerbations. Post hoc and prospective analyses of clinical trial data have confirmed that the multidimensional composite CID endpoint better predicts poorer medium-term outcomes compared with any single CID component alone, and that it can demonstrate differences in treatment efficacy in short-term trials. Given the widely acknowledged need for an individualized holistic approach to COPD management, monitoring short-term CID has the potential to facilitate early identification of suboptimal treatment responses and patients at risk of increased disease progression. CID monitoring may lead to better-informed clinical management decisions and potentially improved prognosis.
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Affiliation(s)
- Dave Singh
- University of Manchester, Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Gerard J Criner
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Ian Naya
- GSK, Respiratory Medicines Development Centre, Stockley Park, Middlesex, UK
- RAMAX Ltd, Bramhall, Cheshire, UK
| | - Paul W Jones
- GSK, Respiratory Medicines Development Centre, Stockley Park, Middlesex, UK
| | | | - David A Lipson
- GSK, Respiratory Clinical Sciences, Collegeville, PA, USA
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
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30
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Martinez FJ, Lipworth BJ, Rabe KF, Collier DJ, Ferguson GT, Sethi S, Feldman GJ, O'Brien G, Jenkins M, Reisner C. Benefits of glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI) in improving lung function and reducing exacerbations in patients with moderate-to-very severe COPD: a pooled analysis of the PINNACLE studies. Respir Res 2020; 21:128. [PMID: 32450869 PMCID: PMC7249639 DOI: 10.1186/s12931-020-01388-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/05/2020] [Indexed: 01/18/2023] Open
Abstract
Background The Phase III PINNACLE studies assessed the efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), a dual long-acting bronchodilator for chronic obstructive pulmonary disease (COPD). Here we present a pre-specified pooled analysis of PINNACLE-1, PINNACLE-2, and PINNACLE-4. Methods PINNACLE-1, -2, and -4 were multicenter, double-blind, randomized controlled trials that enrolled patients with moderate-to-very severe COPD, with no requirement for exacerbation history or a high symptom burden. Patients received GFF MDI 18/9.6 μg, glycopyrrolate (GP) MDI 18 μg, formoterol fumarate (FF) MDI 9.6 μg, or placebo MDI, twice-daily for 24 weeks. The primary endpoint of the pooled analysis was the change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) at week 24. Secondary endpoints included COPD exacerbations and clinically important deterioration (CID). Adverse events were also assessed. Results The pooled intent-to-treat population included 4983 patients; of these, 61.9% had a COPD assessment test (CAT) score ≥15, and 25.0% had experienced ≥1 moderate/severe exacerbation in the past year. At week 24, GFF MDI improved morning pre-dose trough FEV1 versus GP MDI (least squares mean [LSM] difference [95% confidence interval (CI)]: 59 mL [43, 75]), FF MDI (65 mL [48, 81]), and placebo MDI (146 mL [125, 166]); all p < 0.0001. GFF MDI reduced the risk of a moderate/severe exacerbation by 18% (p = 0.0168), 15% (p = 0.0628), and 28% (p = 0.0012) compared with GP MDI, FF MDI, and placebo MDI, respectively. In general, exacerbation risk reduction with GFF MDI versus comparators was greater in subgroups of symptomatic patients (CAT ≥15) and those who had an exacerbation history, than in the pooled intent-to-treat population. The risk of CID was also lower with GFF MDI versus GP MDI (23% decrease), FF MDI (17%), and placebo MDI (49%); all p < 0.0001. All treatments were well tolerated, with no unexpected safety signals. Conclusions This pooled analysis of the PINNACLE studies demonstrated that GFF MDI improved lung function and reduced the risk of exacerbations compared with monocomponents and placebo in patients with COPD. Exacerbation reductions with GFF MDI versus comparators were generally greater in patients with higher symptom burden and those with exacerbation history. Trial registration ClinicalTrials.gov NCT01854645, NCT01854658, and NCT02343458. Registered 13 May 2013 (NCT01854645, NCT01854658) and 6 January 2015 (NCT02343458).
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Affiliation(s)
- Fernando J Martinez
- Weill Cornell Medical College, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, Room M-522, Box 130, New York, NY, 10065, USA.
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Dundee, Scotland, UK
| | - Klaus F Rabe
- LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, Member of the German Center for Lung Research (DZL), Kiel, Germany
| | - David J Collier
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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31
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Koarai A, Sugiura H, Yamada M, Ichikawa T, Fujino N, Kawayama T, Ichinose M. Treatment with LABA versus LAMA for stable COPD: a systematic review and meta-analysis. BMC Pulm Med 2020; 20:111. [PMID: 32349720 PMCID: PMC7191827 DOI: 10.1186/s12890-020-1152-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inhaled bronchodilators including long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) play a central role in the treatment of stable chronic obstructive pulmonary disease (COPD). However, it is still unclear whether LABA or LAMA should be used for the initial treatment. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of LABA versus LAMA in patients with stable COPD. METHODS We searched relevant randomized control trials (RCTs) with a period of treatment of at least 12 weeks and analyzed the exacerbations, quality of life, dyspnea score, lung function and adverse events as the outcomes of interest. RESULTS We carefully excluded unblinded data and identified a total of 19 RCTs (N = 28,211). LAMA significantly decreased the exacerbations compared to LABA (OR 0.85, 95% CI 0.74 to 0.98; P = 0.02). In St George's Respiratory Questionnaire and transitional dyspnoea index score, there were no differences between LABA and LAMA treatment. Compared to LABA, there was a small but significant increase in the trough FEV1 after LAMA treatment (Mean difference 0.02, 95% CI 0.01 to 0.03, P = 0.0006). In the safety components, there was no difference in the serious adverse events between LABA and LAMA. However, LAMA showed a significantly lower incidence of total adverse events compared to LABA (OR 0.92, 95% CI 0.86 to 0.98; P = 0.02). CONCLUSION Treatment with LAMA in stable COPD provided a significantly lower incidence of exacerbation and non-serious adverse events, and a higher trough FEV1 compared to LABA. TRIAL REGISTRATION (PROSPERO: CRD42019144764).
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Affiliation(s)
- Akira Koarai
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Hisatoshi Sugiura
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Mitsuhiro Yamada
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Tomohiro Ichikawa
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Naoya Fujino
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011 Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
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32
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He J, Lin JT. A comparison of tiotropium/olodaterol vs tiotropium alone in terms of treatment effect for chronic obstructive pulmonary disease: A meta-analysis. Medicine (Baltimore) 2020; 99:e19789. [PMID: 32311990 PMCID: PMC7440302 DOI: 10.1097/md.0000000000019789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Combinations of long-acting bronchodilators with different mechanisms of action are recommended to improve prognosis and reduce risk of adverse events of chronic obstructive pulmonary disease (COPD). It is unclear whether the new combination therapy with long-acting muscarinic antagonist (LAMA) tiotropium (TIO) and long acting beta-agonists (LABA) olodaterol (OLO) was superior to tiotropium alone. METHODS We measured the efficacy of the TIO/OLO combination vsTIO alone for COPD patients based on electronic databases up to February 2019. After rigorous quality review, data was extracted from eligible trials. All the main outcomes were pooled analysis using RevMan software. RESULTS A total of 6 randomized controlled trials (RCTs) were identified. The pooled results of our meta-analysis demonstrated that FEV1 [MD = 0.03, 95% CI (-0.01,0.07), P = .18], FVC [MD = -0.03, 95%CI (-0.06,0.00), P = .09] and FEV1%pred [MD = 0.35, 95%CI (-0.30, 0.99), P = .29] all showed no significant difference between the 2 groups. The overall incidence of adverse effects (AEs) [OR = 1.01,95%CI (0.93,1.09), P = .87] and serious AEs [OR = 1.04,95% CI (0.82, 1.32), P = .72] in the combination group was similar to that of the TIO alone group, without statistical significance. CONCLUSION These studies reported that the TIO/OLO combination did not show superior effects than tiotropium alone for COPD. Additionally, both therapies were well tolerated.
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Hillas G, Papaporfyriou A, Dimakou K, Papaioannou AI. Pharmacological treatment of stable COPD: need for a simplified approach. Postgrad Med 2020; 132:126-131. [DOI: 10.1080/00325481.2019.1706996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- G. Hillas
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. Papaporfyriou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
| | - K. Dimakou
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. I. Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
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Martinez FJ, Rabe KF, Lipworth BJ, Arora S, Jenkins M, Martin UJ, Reisner C. Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler Improves Lung Function versus Monotherapies in GOLD Category A Patients with COPD: Pooled Data from the Phase III PINNACLE Studies. Int J Chron Obstruct Pulmon Dis 2020; 15:99-106. [PMID: 32021148 PMCID: PMC6957003 DOI: 10.2147/copd.s229794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/02/2019] [Indexed: 11/23/2022] Open
Abstract
Background The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends a short-acting bronchodilator or single long-acting bronchodilator as an initial pharmacological treatment for GOLD category A patients with COPD. We pooled data from the PINNACLE-1, -2, and -4 studies to evaluate the efficacy and safety of the dual bronchodilator fixed-dose combination glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), formulated using co-suspension delivery technology, in GOLD category A patients with moderate-to-very severe COPD. Materials and Methods PINNACLE-1, -2, and -4 were Phase III, randomized, double-blind, parallel-group, multicenter studies (NCT01854645, NCT01854658, and NCT02343458). Patients received 24 weeks' treatment with GFF MDI 18/9.6 µg, glycopyrrolate (GP) MDI 18 µg, formoterol fumarate (FF) MDI 9.6 µg, or placebo MDI twice daily. GOLD category A patients were identified based on a COPD Assessment Test score of <10 and exacerbation history in the previous year (none/one not requiring hospitalization). Endpoints evaluated were change from baseline in morning pre-dose trough forced expiratory volume in 1 second (FEV1), peak change from baseline in FEV1 within 2 hrs post-dose, and adverse events (AEs). Results The pooled intent-to-treat population comprised 729 GOLD category A patients. GFF MDI significantly improved morning pre-dose trough FEV1 at Week 24 versus GP MDI, FF MDI, and placebo MDI (least squares mean [LSM] differences 54 mL, 62 mL, and 188 mL, respectively; all p≤0.0053), and peak FEV1 at Week 24 versus GP MDI, FF MDI, and placebo MDI (LSM differences 124 mL, 104 mL, and 307 mL, respectively; all p<0.0001). Improvements over 24 weeks were comparable to at Week 24. The AE profile of GFF MDI in GOLD category A patients was similar to monocomponents and placebo MDI. Conclusion GFF MDI significantly improved lung function versus monocomponents and placebo MDI in GOLD category A patients with moderate-to-very severe COPD, with no unexpected safety findings.
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Affiliation(s)
- Fernando J Martinez
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Klaus F Rabe
- Department of Pneumonology, LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Brian J Lipworth
- Division of Molecular and Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Dundee, Scotland, UK
| | | | - Martin Jenkins
- Global Medicines Development, AstraZeneca, Cambridge, UK
| | - Ubaldo J Martin
- Research and Development, AstraZeneca, Gaithersburg, MD, USA
| | - Colin Reisner
- Research and Development, AstraZeneca, Gaithersburg, MD, USA.,R&D Biopharmaceuticals, AstraZeneca, Morristown, NJ, USA
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Maltais F, Bjermer L, Kerwin EM, Jones PW, Watkins ML, Tombs L, Naya IP, Boucot IH, Lipson DA, Compton C, Vahdati-Bolouri M, Vogelmeier CF. Efficacy of umeclidinium/vilanterol versus umeclidinium and salmeterol monotherapies in symptomatic patients with COPD not receiving inhaled corticosteroids: the EMAX randomised trial. Respir Res 2019; 20:238. [PMID: 31666084 PMCID: PMC6821007 DOI: 10.1186/s12931-019-1193-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/20/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Prospective evidence is lacking regarding incremental benefits of long-acting dual- versus mono-bronchodilation in improving symptoms and preventing short-term disease worsening/treatment failure in low exacerbation risk patients with chronic obstructive pulmonary disease (COPD) not receiving inhaled corticosteroids. METHODS The 24-week, double-blind, double-dummy, parallel-group Early MAXimisation of bronchodilation for improving COPD stability (EMAX) trial randomised patients at low exacerbation risk not receiving inhaled corticosteroids, to umeclidinium/vilanterol 62.5/25 μg once-daily, umeclidinium 62.5 μg once-daily or salmeterol 50 μg twice-daily. The primary endpoint was trough forced expiratory volume in 1 s (FEV1) at Week 24. The study was also powered for the secondary endpoint of Transition Dyspnoea Index at Week 24. Other efficacy assessments included spirometry, symptoms, heath status and short-term disease worsening measured by the composite endpoint of clinically important deterioration using three definitions. RESULTS Change from baseline in trough FEV1 at Week 24 was 66 mL (95% confidence interval [CI]: 43, 89) and 141 mL (95% CI: 118, 164) greater with umeclidinium/vilanterol versus umeclidinium and salmeterol, respectively (both p < 0.001). Umeclidinium/vilanterol demonstrated consistent improvements in Transition Dyspnoea Index versus both monotherapies at Week 24 (vs umeclidinium: 0.37 [95% CI: 0.06, 0.68], p = 0.018; vs salmeterol: 0.45 [95% CI: 0.15, 0.76], p = 0.004) and all other symptom measures at all time points. Regardless of the clinically important deterioration definition considered, umeclidinium/vilanterol significantly reduced the risk of a first clinically important deterioration compared with umeclidinium (by 16-25% [p < 0.01]) and salmeterol (by 26-41% [p < 0.001]). Safety profiles were similar between treatments. CONCLUSIONS Umeclidinium/vilanterol consistently provides early and sustained improvements in lung function and symptoms and reduces the risk of deterioration/treatment failure versus umeclidinium or salmeterol in symptomatic patients with low exacerbation risk not receiving inhaled corticosteroids. These findings suggest a potential for early use of dual bronchodilators to help optimise therapy in this patient group.
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Affiliation(s)
- François Maltais
- Centre de Pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada.
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Paul W Jones
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Michael L Watkins
- Respiratory Research and Development, GSK, Research Triangle Park, NC, USA
| | - Lee Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Ian P Naya
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | | | - David A Lipson
- Respiratory Research and Development, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Compton
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Mitra Vahdati-Bolouri
- Respiratory Discovery Medicine, Respiratory Research and Development, GSK, Stevenage, Hertfordshire, UK
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Germany, Member of the German Center for Lung Research (DZL), Marburg, Germany
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Mahler DA, Kerwin E, Murray L, Dembek C. The Impact of Twice-Daily Indacaterol/Glycopyrrolate on the Components of Health-Related Quality of Life and Dyspnea in Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2019; 6. [PMID: 31539467 DOI: 10.15326/jcopdf.6.4.2019.0131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Chronic cough, dyspnea, and excessive sputum production, the characteristic symptoms of chronic obstructive pulmonary disease (COPD), can negatively affect patients' health-related quality of life (HRQoL). The fixed-dose combination of a long-acting beta2-adrenergic agonist and a long-acting muscarinic antagonist (LABA/LAMA) have been shown to improve HRQoL and COPD symptoms as measured by the St George's Respiratory Questionnaire (SGRQ) and the Transition Dyspnea Index (TDI) total scores. However, the impact of a LABA/LAMA on the individual components of HRQoL and dyspnea with daily activities is unknown. Methods Secondary analysis of pooled data from 2 replicate, phase 3, 12-week, randomized, placebo, and active-controlled trials of twice-daily indacaterol/glycopyrrolate (IND/GLY) were analyzed. Change from baseline in HRQoL and dyspnea was measured by SGRQ and TDI, respectively. Total and component scores were evaluated using linear mixed models. Logistic regression was used to analyze the proportion of patients achieving minimum clinically important difference. Study outcomes were further explored in patient subgroups. Results A total of 2038 patients from FLIGHT1/FLIGHT2 studies were evaluated. IND/GLY significantly improved SGRQ component scores (symptoms [-7.3], activity [-3.6], and impacts [-5.0]); all P < 0.001 compared with placebo. IND/GLY also significantly improved symptoms scores compared with IND and GLY (-3.5 and -3.7, respectively; both P < 0.001). Patients treated with IND/GLY also had significant improvements in TDI component scores compared with placebo: functional impairment (0.48), magnitude of task (0.61), and magnitude of effort (0.54); all P < 0.001. All component scores were significantly higher for IND/GLY compared with IND and GLY (P ≤ 0.002 for all). Conclusions Twice-daily IND/GLY significantly improved total scores as well as components of HRQoL and dyspnea in patients with COPD. These data demonstrate multiple clinical benefits of LABA/LAMA maintenance therapy in the COPD population. ClinicalTrials.gov: NCT01727141 and NCT01712516.
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, Oregon
| | | | - Carole Dembek
- Sunovion Pharmaceuticals Inc., Marlborough, Massachusetts
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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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Sobradillo Ecenarro P, García-Rivero JL, López Caro JC. [Bronchodilator therapy in the prevention of COPD exacerbations]. Semergen 2019; 45:479-488. [PMID: 31540819 DOI: 10.1016/j.semerg.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/26/2019] [Accepted: 03/20/2019] [Indexed: 11/28/2022]
Abstract
The natural course of chronic obstructive pulmonary disease usually includes exacerbations. chronic obstructive pulmonary disease patients suffer from 1-4 exacerbations per year on average. These are associated with worsening quality of life and increased mortality. Reducing and controlling the number of exacerbations is one of the main goals of chronic obstructive pulmonary disease treatment. Among current treatments, tiotropium is the active substance with the strongest evidence in the reduction of moderate/severe exacerbations, together with a good safety and tolerability profile. The addition of olodaterol to tiotropium offers well-tolerated and effective double bronchodilation for improving lung function, quality of life, and decreased dyspnoea compared to its single components. This also reduces the annual rate of moderate/severe exacerbations vs. tiotropium by 7%, although not reaching the pre-specified statistical significance level of P<.01.
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Affiliation(s)
- P Sobradillo Ecenarro
- Servicio de Neumología, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España.
| | - J L García-Rivero
- Servicio de Neumología, Hospital de Laredo, Laredo, Cantabria, España
| | - J C López Caro
- Médicina de familia, Centro de Salud Cotolino, Castro Urdiales, Cantabria, España
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Ramadan WH, Al Masri S, Rizk J. Fixed-dose combination of umeclidinium and vilanterol for patients with chronic obstructive pulmonary disease: A systematic review. CLINICAL RESPIRATORY JOURNAL 2019; 13:663-673. [PMID: 31389190 DOI: 10.1111/crj.13073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 06/24/2019] [Accepted: 07/19/2019] [Indexed: 12/11/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common respiratory disease that is predicted to be one of the leading causes of death worldwide. Pharmacologic treatment options of COPD are bronchodilators, using either long-acting β2-agonists (LABAs), or long-acting muscarinic antagonists (LAMAs), or a combination of two. Anoro Ellipta (umeclidinium + vilanterol) dry powder inhaler, a fixed-dose combination of LAMA and LABA, was Food and Drug Administration (FDA) approved in 2013 for COPD. The objective of this study is to evaluate the efficacy and safety of once daily umeclidinium/vilanterol (62.5 mcg/25 mcg) in COPD patients, focusing on pharmacodynamic and pharmacokinetic characteristics, efficacy and safety in clinical studies and cost. Literature search was done through PubMed (2004-2017) using the terms umeclidinium, vilanterol, COPD, LABA and LAMA. Recent and significant clinical trials about the monocomponents and their combination were identified, in addition to reviews, guidelines for COPD, data from manufacturer and FDA product labels. The search was limited to English language studies on human subjects. Clinical data published on the combination of umeclidinium/vilanterol in patients with COPD have shown greater improvements in lung function compared to monotherapies. However, further studies comparing umeclidinium/vilanterol FDC (ANORO) to other LABA/LAMA combinations are needed.
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Affiliation(s)
- Wijdan H Ramadan
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | | | - John Rizk
- Bellevue Medical Center, Mansourieh, Lebanon
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Maltais F, Ferguson GT, Feldman GJ, Deslee G, Bourdin A, Fjällbrant H, Siwek-Posłuszna A, Jenkins MA, Martin UJ. A Randomized, Double-Blind, Double-Dummy Study of Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler Relative to Umeclidinium/Vilanterol Dry Powder Inhaler in COPD. Adv Ther 2019; 36:2434-2449. [PMID: 31267366 DOI: 10.1007/s12325-019-01015-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), formulated using co-suspension delivery technology, is the only approved fixed-dose combination long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) delivered via MDI. Direct comparisons of GFF MDI versus other LAMA/LABAs have not previously been performed. We assessed the efficacy and safety of GFF MDI relative to umeclidinium/vilanterol dry powder inhaler (UV DPI) in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD). METHODS In this phase IIIb randomized, double-blind, double-dummy, multicenter, 24-week study, patients received GFF MDI 18/9.6 μg (equivalent to glycopyrronium/formoterol fumarate dihydrate 14.4/10 μg; two inhalations per dose, twice-daily; n = 559) or UV DPI 62.5/25 μg (one inhalation, once-daily; n = 560). Primary endpoints were change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) and peak change from baseline in FEV1 within 2 h post-dose, both over 24 weeks. Additional lung function, symptom and safety endpoints were also assessed. RESULTS For the primary endpoints, GFF MDI was non-inferior to UV DPI (using a margin of - 50 mL) for peak FEV1 (least squares mean [LSM] difference - 3.4 mL, 97.5% confidence interval [CI] - 32.8, 25.9) but not for trough FEV1 (LSM difference - 87.2 mL; - 117.0, - 57.4). GFF MDI was nominally superior to UV DPI for onset of action (p < 0.0001) and was nominally non-inferior to UV DPI for all symptom endpoints (Transition Dyspnea Index focal score, Early Morning/Night-Time Symptoms COPD instrument scores, and COPD Assessment Test score). Exacerbation and safety findings were similar between groups. CONCLUSIONS Over 24 weeks of treatment, GFF MDI was non-inferior to UV DPI for peak FEV1, but not for morning pre-dose trough FEV1. GFF MDI had a faster onset of action versus UV DPI. There were no clinically meaningful differences between treatments in symptom endpoints. Both treatments were well tolerated with similar safety profiles. TRIAL REGISTRATION NCT03162055 (Clinicaltrials.gov) FUNDING: AstraZeneca.
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Kistemaker LEM, Elzinga CRS, Tautermann CS, Pieper MP, Seeliger D, Alikhil S, Schmidt M, Meurs H, Gosens R. Second M 3 muscarinic receptor binding site contributes to bronchoprotection by tiotropium. Br J Pharmacol 2019; 176:2864-2876. [PMID: 31077341 DOI: 10.1111/bph.14707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 04/16/2019] [Accepted: 04/29/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND PURPOSE The bronchodilator tiotropium binds not only to its main binding site on the M3 muscarinic receptor but also to an allosteric site. Here, we have investigated the functional relevance of this allosteric binding and the potential contribution of this behaviour to interactions with long-acting β-adrenoceptor agonists, as combination therapy with anticholinergic agents and β-adrenoceptor agonists improves lung function in chronic obstructive pulmonary disease. EXPERIMENTAL APPROACH ACh, tiotropium, and atropine binding to M3 receptors were modelled using molecular dynamics simulations. Contractions of bovine and human tracheal smooth muscle strips were studied. KEY RESULTS Molecular dynamics simulation revealed extracellular vestibule binding of tiotropium, and not atropine, to M3 receptors as a secondary low affinity binding site, preventing ACh entry into the orthosteric binding pocket. This resulted in a low (allosteric binding) and high (orthosteric binding) functional affinity of tiotropium in protecting against methacholine-induced contractions of airway smooth muscle, which was not observed for atropine and glycopyrrolate. Moreover, antagonism by tiotropium was insurmountable in nature. This behaviour facilitated functional interactions of tiotropium with the β-agonist olodaterol, which synergistically enhanced bronchoprotective effects of tiotropium. This was not seen for glycopyrrolate and olodaterol or indacaterol but was mimicked by the interaction of tiotropium and forskolin, indicating no direct β-adrenoceptor-M3 receptor crosstalk in this effect. CONCLUSIONS AND IMPLICATIONS We propose that tiotropium has two binding sites at the M3 receptor that prevent ACh action, which, together with slow dissociation kinetics, may contribute to insurmountable antagonism and enhanced functional interactions with β-adrenoceptor agonists.
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Affiliation(s)
- Loes E M Kistemaker
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carolina R S Elzinga
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christofer S Tautermann
- Department of Medicinal Chemistry, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Michael P Pieper
- Immunology and Respiratory Disease Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Daniel Seeliger
- Department of Medicinal Chemistry, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Suraya Alikhil
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martina Schmidt
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Herman Meurs
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud Gosens
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Albertson TE, Bowman WS, Harper RW, Godbout RM, Murin S. Evidence-based review of data on the combination inhaler umeclidinium/vilanterol in patients with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:1251-1265. [PMID: 31239659 PMCID: PMC6559138 DOI: 10.2147/copd.s191845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/25/2019] [Indexed: 01/10/2023] Open
Abstract
The use of inhaled, fixed-dose, long-acting muscarinic antagonists (LAMA) combined with long-acting, beta2-adrenergic receptor agonists (LABA) has become a mainstay in the maintenance treatment of chronic obstructive pulmonary disease (COPD). One of the fixed-dose LAMA/LABA combinations is the dry powder inhaler (DPI) of umeclidinium bromide (UMEC) and vilanterol trifenatate (VI) (62.5 µg/25 µg) approved for once-a-day maintenance treatment of COPD. This paper reviews the use of fixed-dose combination LAMA/LABA agents focusing on the UMEC/VI DPI inhaler in the maintenance treatment of COPD. The fixed-dose combination LAMA/LABA inhaler offers a step beyond a single inhaled maintenance agent but is still a single device for the COPD patient having frequent COPD exacerbations and persistent symptoms not well controlled on one agent. Currently available clinical trials suggest that the once-a-day DPI of UMEC/VI is well-tolerated, safe and non-inferior or better than other currently available inhaled fixed-dose LAMA/LABA combinations for COPD.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis, Sacramento, CA, USA
- Department of Veterans Affairs, Northern California Health Care System, Mather, CA, USA
| | - Willis S Bowman
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis, Sacramento, CA, USA
- Department of Veterans Affairs, Northern California Health Care System, Mather, CA, USA
| | - Richart W Harper
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis, Sacramento, CA, USA
- Department of Veterans Affairs, Northern California Health Care System, Mather, CA, USA
| | - Regina M Godbout
- Department of Veterans Affairs, Northern California Health Care System, Mather, CA, USA
- Department of Internal Medicine, Division of General Medicine, UC Davis, Sacramento, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis, Sacramento, CA, USA
- Department of Veterans Affairs, Northern California Health Care System, Mather, CA, USA
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Hahn B, Stanford RH, Goolsby Hunter A, Essoi B, White J, Ray R. Patient-Reported Burden of Illness in a Prevalent COPD Population Treated with Long-Acting Muscarinic Antagonist Monotherapy: A Claims-Linked Patient Survey Study. Pulm Ther 2019; 5:69-80. [PMID: 32026428 PMCID: PMC6967076 DOI: 10.1007/s41030-019-0091-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Symptom burden in inadequately controlled chronic obstructive pulmonary disease (COPD) considerably impacts quality of life, healthcare resource utilization (HCRU) and associated costs. This claims-linked cross-sectional survey study assessed symptom burden and HCRU among a prevalent population of COPD patients prescribed long-acting muscarinic antagonist (LAMA) monotherapy. METHODS Patients were identified using claims data from the Optum Research Database. Eligible patients were aged ≥ 40 years with 12 months' continuous enrollment in a US health plan, ≥ 2 medical claims containing COPD diagnosis codes ≥ 30 days apart, and ≥ 2 claims for LAMA monotherapy in the latter half of the 12-month sample identification period. Patients were mailed a cross-sectional survey assessing patient-reported outcomes (PROs) [COPD assessment test (CAT) and modified medical research council dyspnea scale (mMRC)], clinical characteristics, smoking history, and demographics. Patients also completed the Exacerbations of Chronic Pulmonary Disease Tool (EXACT-PRO) daily diary for 7 days. HCRU was assessed from claims data. RESULTS The study included 433 patients with a self-reported healthcare provider COPD diagnosis, and both claims-based and self-reported LAMA monotherapy treatment (mean age 71.0 years; 59.8% female). Most patients (85.5%) reported a high symptom burden (CAT score ≥ 10), 45.5% had high levels of dyspnea (mMRC grade ≥ 2), and 64.4% reported more severe daily symptoms by the EXACT-PRO. Most patients (71.6%) reported high scores on ≥ 2 PROs. More patients with high symptom burden had COPD-related emergency department visits than those with lower disease burden (27.6% vs 12.7%, P = 0.012). CONCLUSIONS In conclusion, a large proportion of patients with COPD receiving LAMA monotherapy experienced a high symptom burden and may benefit from therapy escalation. Healthcare professionals can use validated PROs to help them assess symptom burden. FUNDING GlaxoSmithKline (GSK study number: 205862).
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Affiliation(s)
- Beth Hahn
- US Value Evidence and Outcomes, GSK, 5 Moore Drive, Research Triangle Park, NC, 27709-3398, USA.
| | - Richard H Stanford
- US Value Evidence and Outcomes, GSK, 5 Moore Drive, Research Triangle Park, NC, 27709-3398, USA
| | - Alyssa Goolsby Hunter
- Health Economics and Outcomes Research, Optum, 11000 Optum Circle, Eden Prairie, MN, 55344, USA
| | - Breanna Essoi
- Health Economics and Outcomes Research, Optum, 11000 Optum Circle, Eden Prairie, MN, 55344, USA
| | - John White
- Health Economics and Outcomes Research, Optum, 11000 Optum Circle, Eden Prairie, MN, 55344, USA
| | - Riju Ray
- US Medical Affairs, GSK, 5 Moore Drive, Research Triangle Park, NC, 27709-3398, USA
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Ray R, Tombs L, Naya I, Compton C, Lipson DA, Boucot I. Efficacy and safety of the dual bronchodilator combination umeclidinium/vilanterol in COPD by age and airflow limitation severity: A pooled post hoc analysis of seven clinical trials. Pulm Pharmacol Ther 2019; 57:101802. [PMID: 31096036 DOI: 10.1016/j.pupt.2019.101802] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Elderly patients with chronic obstructive pulmonary disease (COPD) and those with more severe airway limitation are perceived to experience reduced efficacy from inhaled bronchodilators, especially those administered in a dry powder inhaler. This study compared the efficacy and safety of a long-acting muscarinic antagonist/long-acting β2-agonist dry powder combination in elderly patients with COPD and patients with moderate-to-very severe airflow limitation. METHODS This post hoc pooled analysis of seven randomized studies of ≥12 weeks' duration investigated the efficacy and safety of umeclidinium/vilanterol (UMEC/VI) 62.5/25 μg versus tiotropium (TIO) 18 μg or fluticasone propionate/salmeterol (FP/SAL) 250/50 μg. Change from baseline in trough forced expiratory volume in 1 s (FEV1), a common efficacy measure in all trials, proportion of FEV1 responders (≥100 mL increase from baseline) and safety outcomes were analyzed at Day 28, 56, and 84 in patients classified by age (<65, ≥65, and ≥75 years of age) and severity of baseline airflow limitation (Global initiative for chronic Obstructive Lung Disease [GOLD] stage 2 [moderate] and stage 3/4 [severe/very severe]). A 24-week analysis was also conducted for the UMEC/VI versus TIO comparison. RESULTS The pooled intent-to-treat population comprised 3821 patients (≥65 years: 44-45%; ≥75 years: 9-10%; GOLD stage 3/4: 50-55%); 2246, 874, and 701 patients received UMEC/VI, TIO, or FP/SAL, respectively. Significant improvements in trough FEV1 at Day 84 were observed with UMEC/VI versus TIO or FP/SAL irrespective of age (all p ≤ 0.029) or GOLD stage (all p < 0.001). The proportion of FEV1 responders at Day 84 was significantly greater with UMEC/VI versus TIO or FP/SAL across all age groups (all p ≤ 0.016) and GOLD stages (all p < 0.001). Safety profiles were similar between treatment groups. CONCLUSION UMEC/VI consistently demonstrated improved lung function versus TIO and FP/SAL across age and airflow limitation severity subgroups, with no safety concerns, indicating that UMEC/VI provides no loss in efficacy or additional safety concerns for both elderly patients with COPD and patients with severe/very severe airway limitation.
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Affiliation(s)
- Riju Ray
- US Medical Affairs, GSK, 5 Moore Drive, Research Triangle Park, NC, 27709-3398, USA.
| | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK.
| | - Ian Naya
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, UK.
| | - Chris Compton
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, UK.
| | - David A Lipson
- Respiratory Research and Development, GSK, 1250 S Collegeville Rd, Collegeville, PA, PA, 19426, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Isabelle Boucot
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, UK.
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Malerba M, Foci V, Patrucco F, Pochetti P, Nardin M, Pelaia C, Radaeli A. Single Inhaler LABA/LAMA for COPD. Front Pharmacol 2019; 10:390. [PMID: 31105560 PMCID: PMC6494943 DOI: 10.3389/fphar.2019.00390] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/29/2019] [Indexed: 01/04/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a common disabling disease characterized by progressive airflow obstruction. Great efforts were spent in the development of drugs able to improve symptoms, quality of life, reduce exacerbations, hospitalizations and the frequency of death of patients with COPD. The cornerstones of treatment are bronchodilator drugs of two different classes: beta agonists and muscarinic antagonists. Currently the Global initiative for COPD suggests the use of long acting beta agonists (LABAs) and long acting muscarinic antagonists (LAMAs) in combination for the majority of COPD patients, thus great interest is associated with the developing of LAMA/LABA fixed combination in the maintenance treatment of stable COPD. Many LAMA/LABA fixed dose combinations have been licensed in different countries and the clinical use of these drugs stimulated the performance of many clinical trials. The purpose of this review is a complete criticism of pharmacological and clinical aspects related to the use of LAMA/LABA single inhalers for the maintenance treatment of stable COPD, with particular mention to the most debated topics and future prospects in the field.
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Affiliation(s)
- Mario Malerba
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
- Respiratory Unit, Sant’Andrea Hospital, Vercelli, Italy
| | - Valentina Foci
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
- Respiratory Unit, Sant’Andrea Hospital, Vercelli, Italy
| | - Filippo Patrucco
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
- Respiratory Unit, Sant’Andrea Hospital, Vercelli, Italy
| | - Patrizia Pochetti
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
- Respiratory Unit, Sant’Andrea Hospital, Vercelli, Italy
| | - Matteo Nardin
- Department of Medicine, Spedali Civili di Brescia, Brescia, Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
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Crim C, Watkins ML, Bateman ED, Feldman GJ, Schenkenberger I, Kerwin EM, Crawford C, Pudi K, Ho S, Baidoo C, Castro-Santamaria R. Randomized dose-finding study of batefenterol via dry powder inhaler in patients with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:615-629. [PMID: 30880951 PMCID: PMC6413745 DOI: 10.2147/copd.s190603] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Batefenterol is a novel bifunctional muscarinic antagonist β2-agonist in development for COPD. The primary objective of this randomized, double-blind, placebo-controlled, active comparator, Phase IIb study was to model the dose–response of batefenterol and select a dose for Phase III development. Patients and methods Patients aged ≥40 years with COPD and FEV1 ≥30% and ≤70% predicted normal were randomized equally to batefenterol 37.5, 75, 150, 300, or 600 µg, placebo, or umeclidinium/vilanterol (UMEC/VI) 62.5/25 µg once daily. The primary and secondary endpoints were weighted-mean FEV1 over 0–6 hours post-dose and trough FEV1, analyzed by Bayesian and maximum likelihood estimation Emax of dose–response modeling, respectively, on day 42. Results In the intent-to-treat population (N=323), all batefenterol doses demonstrated statistically and clinically significant improvements from baseline vs placebo in the primary and secondary endpoints (191.1–292.8 and 182.2–244.8 mL, respectively), with a relatively flat dose–response. In the subgroup reversible to salbutamol, there were greater differences between batefenterol doses. Lung function improvements with batefenterol ≥150 µg were comparable with those with UMEC/VI. Batefenterol was well tolerated and no new safety signals were observed. Conclusion Batefenterol 300 µg may represent the optimal dose for Phase III studies.
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Affiliation(s)
- Courtney Crim
- GSK, Research and Development, Research Triangle Park, NC, USA,
| | | | - Eric D Bateman
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Edward M Kerwin
- Clinical Trials Division, Crisor LLC, Clinical Research Institute, Medford OR, USA
| | | | - Krishna Pudi
- Upstate Pharmaceutical Research, Greenville, SC, USA
| | - Shuyen Ho
- PAREXEL International, Durham, NC, USA
| | - Charlotte Baidoo
- GSK, Clinical Statistics, Stockley Park, Uxbridge, Middlesex, UK
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Maqsood U, Ho TN, Palmer K, Eccles FJR, Munavvar M, Wang R, Crossingham I, Evans DJW. Once daily long-acting beta2-agonists and long-acting muscarinic antagonists in a combined inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2019; 3:CD012930. [PMID: 30839102 PMCID: PMC6402279 DOI: 10.1002/14651858.cd012930.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a respiratory condition causing accumulation of mucus in the airways, cough, and breathlessness; the disease is progressive and is the fourth most common cause of death worldwide. Current treatment strategies for COPD are multi-modal and aim to reduce morbidity and mortality and increase patients' quality of life by slowing disease progression and preventing exacerbations. Fixed-dose combinations (FDCs) of a long-acting beta2-agonist (LABA) plus a long-acting muscarinic antagonist (LAMA) delivered via a single inhaler are approved by regulatory authorities in the USA, Europe, and Japan for the treatment of COPD. Several LABA/LAMA FDCs are available and recent meta-analyses have clarified their utility versus their mono-components in COPD. Evaluation of the efficacy and safety of once-daily LABA/LAMA FDCs versus placebo will facilitate the comparison of different FDCs in future network meta-analyses. OBJECTIVES We assessed the evidence for once-daily LABA/LAMA combinations (delivered in a single inhaler) versus placebo on clinically meaningful outcomes in patients with stable COPD. SEARCH METHODS We identified trials from Cochrane Airways' Specialised Register (CASR) and also conducted a search of the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch). We searched CASR and trial registries from their inception to 3 December 2018; we imposed no restriction on language of publication. SELECTION CRITERIA We included parallel-group and cross-over randomised controlled trials (RCTs) comparing once-daily LABA/LAMA FDC versus placebo. We included studies reported as full-text, those published as abstract only, and unpublished data. We excluded very short-term trials with a duration of less than 3 weeks. We included adults (≥ 40 years old) with a diagnosis of stable COPD. We included studies that allowed participants to continue using their ICS during the trial as long as the ICS was not part of the randomised treatment. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results to determine included studies, extracted data on prespecified outcomes of interest, and assessed the risk of bias of included studies; we resolved disagreements by discussion with a third review author. Where possible, we used a random-effects model to meta-analyse extracted data. We rated all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system and presented results in 'Summary of findings' tables. MAIN RESULTS We identified and included 22 RCTs randomly assigning 8641 people with COPD to either once-daily LABA/LAMA FDC (6252 participants) or placebo (3819 participants); nine studies had a cross-over design. Studies had a duration of between three and 52 weeks (median 12 weeks). The mean age of participants across the included studies ranged from 59 to 65 years and in 21 of 22 studies, participants had GOLD stage II or III COPD. Concomitant inhaled corticosteroid (ICS) use was permitted in all of the included studies (where stated); across the included studies, between 28% to 58% of participants were using ICS at baseline. Six studies evaluated the once-daily combination of IND/GLY (110/50 μg), seven studies evaluated TIO/OLO (2.5/5 or 5/5 μg), eight studies evaluated UMEC/VI (62.5/5, 125/25 or 500/25 μg) and one study evaluated ACD/FOR (200/6, 200/12 or 200/18 μg); all LABA/LAMA combinations were compared with placebo.The risk of bias was generally considered to be low or unknown (insufficient detail provided), with only one study per domain considered to have a high risk of bias except for the domain 'other bias' which was determined to be at high risk of bias in four studies (in three studies, disease severity was greater at baseline in participants receiving LABA/LAMA compared with participants receiving placebo, which would be expected to shift the treatment effect in favour of placebo).Compared to the placebo, the pooled results for the primary outcomes for the once-daily LABA/LAMA arm were as follows: all-cause mortality, OR 1.88 (95% CI 0.81 to 4.36, low-certainty evidence); all-cause serious adverse events (SAEs), OR 1.06 (95% CI 0.88 to 1.28, high-certainty evidence); acute exacerbations of COPD (AECOPD), OR 0.53 (95% CI 0.36 to 0.78, moderate-certainty evidence); adjusted St George's Respiratory Questionnaire (SGRQ) score, MD -4.08 (95% CI -4.80 to -3.36, high-certainty evidence); proportion of SGRQ responders, OR 1.75 (95% CI 1.54 to 1.99). Compared with placebo, the pooled results for the secondary outcomes for the once-daily LABA/LAMA arm were as follows: adjusted trough forced expiratory volume in one second (FEV1), MD 0.20 L (95% CI 0.19 to 0.21, moderate-certainty evidence); adjusted peak FEV1, MD 0.31 L (95% CI 0.29 to 0.32, moderate-certainty evidence); and all-cause AEs, OR 0.95 (95% CI 0.86 to 1.04; high-certainty evidence). No studies reported data for the 6-minute walk test. The results were generally consistent across subgroups for different LABA/LAMA combinations and doses. AUTHORS' CONCLUSIONS Compared with placebo, once-daily LABA/LAMA (either IND/GLY, UMEC/VI or TIO/OLO) via a combination inhaler is associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild-to-moderate COPD; UMEC/VI appears to reduce the rate of exacerbations in this population. These conclusions are supported by moderate or high certainty evidence based on studies with an observation period of up to one year.
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Affiliation(s)
- Usman Maqsood
- Sandwell and West Birmingham Hospitals NHS TrustDepartment of Respiratory MedicineBirminghamUK
| | - Terence N Ho
- St. Joseph's HealthcareFirestone Institute for Respiratory HealthHamiltonOntarioCanada
- McMaster UniversityHamiltonOntarioCanada
| | - Karen Palmer
- Lancashire Care NHS Foundation TrustNIHR Lancashire CRFPrestonUK
| | | | - Mohammed Munavvar
- Lancashire Teaching Hospitals NHS Foundation TrustDepartment of Respiratory MedicinePrestonUK
| | - Ran Wang
- Lancashire Teaching Hospitals NHS Foundation TrustDepartment of Respiratory MedicinePrestonUK
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Dual bronchodilator therapy for chronic obstructive pulmonary disease: evidence for the efficacy and Safety of fixed dose combination treatments in the setting of recent guideline updates. Curr Opin Pulm Med 2019; 24:130-137. [PMID: 29206657 DOI: 10.1097/mcp.0000000000000450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW Recent updates to the GOLD guidelines emphasize the use of combination LABA and LAMA bronchodilators for patients with chronic obstructive pulmonary disease with persistent dyspnea despite monotherapy or frequent exacerbations despite LAMA monotherapy. There are several commercially available LABA/LAMA fixed dose combination inhalers, which are likely to become the principle therapy for many patients with COPD. RECENT FINDINGS In the last 4 years, there have been a number of large clinical trials evaluating the efficacy and safety of combined LAMA and LABA bronchodilators. LAMA/LABA fixed dose combination therapies have consistently demonstrated clinically significant improvements to airway obstruction, dyspnea, and quality of life whenever compared with placebo, and more modest improvements compared with bronchodilator monotherapies and combined bronchodilator/inhaled corticosteroid therapy. SUMMARY New guidelines emphasize combination bronchodilators as a mainstay of therapy for many patients with symptomatic COPD and there are several new combination bronchodilator therapies available to patients. It is important for physicians and patients to understand the range and degree of expected clinical effects and the safety profiles of these new medications.
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Wang MT, Lai JH, Tsai CL, Liou JT. Risk of adverse cardiovascular events with use of inhaled long-acting bronchodilators in management of chronic obstructive pulmonary disease. J Food Drug Anal 2019; 27:657-670. [PMID: 31324282 PMCID: PMC9307027 DOI: 10.1016/j.jfda.2018.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 01/01/2023] Open
Abstract
Inhaled long-acting bronchodilators, including long-acting β2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) are the mainstay therapy in the treatment of chronic obstructive pulmonary disease (COPD), a disease that poses a heavy burden on morbidity and mortality worldwide. Use of LABAs and LAMAs in patients with COPD, however, has been concerned about an increased risk of adverse cardiovascular events, despite inconsistent findings reported from randomized controlled trials (RCTs) and observational studies. In this review, we detailed the relevant evidence generated from RCTs and observational studies with respect to the risk of cardiovascular disease with use of LABAs and LAMAs in management of COPD, and analyzed the contradictory findings in the literature, as well as recommended future research directions to clear the air regarding the cardiovascular safety of inhaled long-acting bronchodilators.
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Affiliation(s)
- Meng-Ting Wang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan.
| | - Jyun-Heng Lai
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan.
| | - Chen-Liang Tsai
- Division of Pulmonary and Critical Care, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| | - Jun-Ting Liou
- Division of Cardiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Martinez FJ, Abrahams RA, Ferguson GT, Bjermer L, Grönke L, Voß F, Singh D. Effects of baseline symptom burden on treatment response in COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:181-194. [PMID: 30655665 PMCID: PMC6324615 DOI: 10.2147/copd.s179912] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
RATIONALE In symptomatic patients with COPD, the decision whether to initiate maintenance treatment with a single agent or a combination of long-acting bronchodilators remains unclear. OBJECTIVE To investigate whether baseline symptomatic status influences response to tiotropium/olodaterol treatment. MATERIALS AND METHODS Post hoc analysis of the randomized OTEMTO® studies (NCT01964352; NCT02006732), in which patients with moderate-to-severe COPD received placebo, tiotropium 5 µg, tiotropium/olodaterol 2.5/5 µg, or tiotropium/olodaterol 5/5 µg once daily for 12 weeks via the Respimat® inhaler (Boehringer Ingelheim, Ingelheim am Rhein, Germany). Impact of baseline symptomatic status (modified Medical Research Council [mMRC] score) on response to treatment with tiotropium/olodaterol 5/5 µg, tiotropium 5 µg, or placebo at Week 12 was assessed by St George's Respiratory Questionnaire (SGRQ) total score and response rate, transition dyspnea index (TDI) focal score and response rate, and trough forced expiratory volume in 1 second response. RESULTS Tiotropium/olodaterol improved SGRQ total scores and response rates compared with placebo and tiotropium for patients with baseline mMRC scores 0-1 and ≥2. For tiotropium/olodaterol vs tiotropium, greater improvements were observed for patients with mMRC ≥2 (SGRQ score adjusted mean treatment difference -3.44 [95% CI: -5.43, -1.46]; P=0.0007; SGRQ response rate ORs 2.09 [95% CI: 1.41, 3.10]; P=0.0002). Dyspnea, measured by TDI score, was consistently improved with tiotropium/olodaterol vs placebo for patients with mMRC scores 0-1 and ≥2 (adjusted mean treatment difference 1.63 [95% CI: 1.06, 2.20]; P<0.0001 and 1.60 [95% CI: 1.09, 2.10]; P<0.0001, respectively). In patients with mMRC scores 0-1 and ≥2, tiotropium/olodaterol consistently improved TDI response rate and lung function vs placebo and tiotropium. CONCLUSIONS Patients with COPD with more severe baseline dyspnea appear to derive greater health status benefit with tiotropium/olodaterol compared with tiotropium alone.
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Affiliation(s)
- Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA,
| | - Roger A Abrahams
- Morgantown Pulmonary Clinical Research, Morgantown, WV, USA
- Department of Pulmonary & Critical Care, Mon Health Care, Morgantown, WV, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Lars Grönke
- Biotechnology, CSL Behring, Wiesbaden, Germany
| | - Florian Voß
- Biostatistics + Data Sciences Corp., Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
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