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Braghiroli A, Braido F, Piraino A, Rogliani P, Santus P, Scichilone N. Day and Night Control of COPD and Role of Pharmacotherapy: A Review. Int J Chron Obstruct Pulmon Dis 2020; 15:1269-1285. [PMID: 32606638 PMCID: PMC7283230 DOI: 10.2147/copd.s240033] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/03/2020] [Indexed: 12/30/2022] Open
Abstract
The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients’ adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient’s profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic “24-hour control of COPD and role of pharmacotherapy”, held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine. ![]()
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Affiliation(s)
- Alberto Braghiroli
- Department of Pulmonary Rehabilitation, Sleep Laboratory, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno, NO, Italy
| | - Fulvio Braido
- Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, Azienda Policlinico IRCCS San Martino, Genoa, Italy
| | - Alessio Piraino
- Respiratory Area, Medical Affairs Chiesi Italia, Parma, Italy
| | - Paola Rogliani
- Respiratory Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Pierachille Santus
- Pierachille Santus, Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy
| | - Nicola Scichilone
- Department of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, Italy
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Albertson TE, Chenoweth JA, Pearson SJ, Murin S. The pharmacological management of asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). Expert Opin Pharmacother 2020; 21:213-231. [PMID: 31955671 DOI: 10.1080/14656566.2019.1701656] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) is a disease phenotype that shares T helper lymphocyte cell Th1/neutrophilic/non-Type-2 Inflammation pathways thought to be key in COPD and Th2/eosinophilic/Type-2 inflammatory pathways of asthma. The pharmacology of treating ACOS is challenging in severe circumstances.Areas covered: This review evaluates the stepwise treatment of ACOS using pharmacological treatments used in both COPD and asthma. The most common medications involve the same inhalers used to treat COPD and asthma patients. Advanced stepwise therapies for ACOS patients are based on patient characteristics and biomarkers. Very few clinical trials exist that focus specifically on ACOS patients.Expert opinion: After inhalers, advanced therapies including phosphodiesterase inhibitors, macrolides, N-acetylcysteine and statin therapy for those ACOS patients with a COPD appearance and exacerbations are available. In atopic ACOS patients with exacerbations, advanced asthma therapies (leukotriene receptor antagonists and synthesis blocking agents.) are used. ACOS patients with elevated blood eosinophil/IgE levels are considered for immunotherapy or therapeutic monoclonal antibodies blocking specific Th2/Type-2 interleukins or IgE. Symptom control, stabilization/improvement in pulmonary function and reduced exacerbations are the metrics of success. More pharmacological trials of ACOS patients are needed to better understand which patients benefit from specific treatments.Abbreviations: 5-LOi: 5-lipoxygenase inhibitor; ACOS: asthma - COPD overlap syndrome; B2AR: Beta2 adrenergic receptors; cAMP: cyclic adenosine monophosphate; cGMP: cyclic guanosine monophosphate; CI: confidence interval; COPD: chronic obstructive pulmonary disease; CRS : chronic rhinosinusitis; cys-LT: cysteinyl leukotrienes; DPI: dry powder inhaler; EMA: European Medicines Agency; FDA: US Food and Drug Administration; FDC: fixed-dose combination; FeNO: exhaled nitric oxide; FEV1: forced expiratory volume in one second; FVC: forced vital capacity; GM-CSF: granulocyte-macrophage colony-stimulating factor; ICS : inhaled corticosteroids; IL: interleukin; ILC2: Type 2 innate lymphoid cells; IP3: Inositol triphosphate; IRR: incidence rate ratio; KOLD: Korean Obstructive Lung Disease; LABA: long-acting B2 adrenergic receptor agonist; LAMA: long-acting muscarinic receptor antagonist; LRA: leukotriene receptor antagonist; LT: leukotrienes; MDI: metered-dose inhalers; MN: M-subtype muscarinic receptors; MRA: muscarinic receptor antagonist; NAC: N-acetylcysteine; NEB: nebulization; OR: odds ratio; PDE: phosphodiesterase; PEFR: peak expiratory flow rate; PGD2: prostaglandin D2; PRN: as needed; RR: risk ratio; SABA: short-acting B2 adrenergic receptor agonist; SAMA: short-acting muscarinic receptor antagonist; SDMI: spring-driven mist inhaler; Th1: T helper cell 1 lymphocyte; Th2: T helper cell 2 lymphocytes; TNF-α: tumor necrosis factor alpha; US : United States.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Skyler J Pearson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Susan Murin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
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Alvarado-Gonzalez A, Arce I. Tiotropium Bromide in Chronic Obstructive Pulmonary Disease and Bronchial Asthma. J Clin Med Res 2015; 7:831-9. [PMID: 26491494 PMCID: PMC4596263 DOI: 10.14740/jocmr2305w] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2015] [Indexed: 12/19/2022] Open
Abstract
Inhaled bronchodilators are the mainstay of pharmacological treatment for stable chronic obstructive pulmonary disease (COPD), including β2-agonists and muscarinic antagonists. Tiotropium bromide, a long-acting antimuscarinic bronchodilator (LAMA), is a treatment choice for moderate-to-severe COPD; its efficacy and safety have been demonstrated in recent trials. Studies also point to a beneficial role of tiotropium in the treatment of difficult-to-control asthma and a potential function in the asthma-COPD overlap syndrome (ACOS). Combination of different bronchodilator molecules and addition of inhaled corticosteroids are viable therapeutic alternatives. A condensation of the latest trials and the rationale behind these therapies will be presented in this article.
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Affiliation(s)
| | - Isabel Arce
- Medicine and General Surgery, Clinica de Diagnostico Medico, San Jose, Costa Rica
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Cazzola M, Rogliani P, Matera MG. Escalation and De-escalation of Therapy in COPD: Myths, Realities and Perspectives. Drugs 2015; 75:1575-85. [DOI: 10.1007/s40265-015-0450-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Grouse L. Selective polypharmacy for chronic obstructive pulmonary disease. J Thorac Dis 2015; 7:E16-8. [PMID: 25922741 DOI: 10.3978/j.issn.2072-1439.2015.01.40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 12/05/2014] [Indexed: 11/14/2022]
Affiliation(s)
- Lawrence Grouse
- Department of Neurology, University of Washington School of Medicine, Washington, USA
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Inhaled corticosteroids withdrawal in severe patients with chronic obstructive pulmonary disease: a wisdom decision? Arch Bronconeumol 2015; 51:57-58. [PMID: 25563900 DOI: 10.1016/j.arbres.2014.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 11/20/2022]
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D'Urzo A, Donohue JF, Kardos P, Miravitlles M, Price D. A re-evaluation of the role of inhaled corticosteroids in the management of patients with chronic obstructive pulmonary disease. Expert Opin Pharmacother 2015; 16:1845-60. [PMID: 26194213 PMCID: PMC4673525 DOI: 10.1517/14656566.2015.1067682] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) (in fixed combinations with long-acting β2-agonists [LABAs]) are frequently prescribed for patients with chronic obstructive pulmonary disease (COPD), outside their labeled indications and recommended treatment strategies and guidelines, despite having the potential to cause significant side effects. AREAS COVERED Although the existence of asthma in patients with asthma-COPD overlap syndrome (ACOS) clearly supports the use of anti-inflammatory treatment (typically an ICS/LABA combination, as ICS monotherapy is usually not indicated for COPD), the current level of ICS/LABA use is not consistent with the prevalence of ACOS in the COPD population. Data have recently become available showing the comparative efficacy of fixed bronchodilator combinations (long-acting muscarinic antagonist [LAMA]/LABA with ICS/LABA combinations). Additionally, new information has emerged on ICS withdrawal without increased risk of exacerbations, under cover of effective bronchodilation. EXPERT OPINION For patients with COPD who do not have ACOS, a LAMA/LABA combination may be an appropriate starting therapy, apart from those with mild disease who can be managed with a single long-acting bronchodilator. Patients who remain symptomatic or present with exacerbations despite effectively delivered LAMA/LABA treatment may require additional drug therapy, such as ICS or phosphodiesterase-4 inhibitors. When prescribing an ICS/LABA, the risk:benefit ratio should be considered in individual patients.
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Affiliation(s)
- Anthony D'Urzo
- University of Toronto, Department of Family and Community Medicine , 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7 , Canada +1 416 652 9336 ; +1 416 652 0218 ;
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