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Eilat-Tsanani S, Ernst P, Suissa S. Real-World Effectiveness of Single-Inhaler Triple Therapy for COPD: Impact of Diabetes Comorbidity. COPD 2024; 21:2327345. [PMID: 38509685 DOI: 10.1080/15412555.2024.2327345] [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] [Received: 02/05/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
Abstract
Type 2 diabetes is a frequent comorbidity in chronic obstructive pulmonary disease (COPD) patients, with the GOLD treatment recommendations asserting that the presence of diabetes be disregarded in the choice of treatment. In a cohort of COPD patients with frequent exacerbations, initiators of single-inhaler triple therapy or dual bronchodilators were compared on the incidence of COPD exacerbation and pneumonia over one year, adjusted by propensity score weighting and stratified by type 2 diabetes. The COPD cohort included 1,114 initiators of triple inhalers and 4,233 of dual bronchodilators (28% with type 2 diabetes). The adjusted hazard ratio (HR) of exacerbation with triple therapy was 1.04 (95% CI: 0.86-1.25) among COPD patients with type 2 diabetes and 0.74 (0.65-0.85) in those without. The incidence of severe pneumonia was elevated with triple therapy among patients with type 2 diabetes (HR 1.77; 1.14-2.75). Triple therapy in COPD is effective among those without, but not those with, type 2 diabetes. Future therapeutic trials in COPD should consider diabetes comorbidity.
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Affiliation(s)
- Sophia Eilat-Tsanani
- Department of Family Medicine, Clalit Health Services, North District, Israel
- Department of Family Medicine, Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, Canada
- Department of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, Canada
- Department of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Canada
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Singh D, Han MK, Hawkins NM, Hurst JR, Kocks JWH, Skolnik N, Stolz D, El Khoury J, Gale CP. Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review. Adv Ther 2024; 41:2151-2167. [PMID: 38664329 PMCID: PMC11133105 DOI: 10.1007/s12325-024-02855-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/22/2024] [Indexed: 05/29/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) constitutes a major global health burden and is the third leading cause of death worldwide. A high proportion of patients with COPD have cardiovascular disease, but there is also evidence that COPD is a risk factor for adverse outcomes in cardiovascular disease. Patients with COPD frequently die of respiratory and cardiovascular causes, yet the identification and management of cardiopulmonary risk remain suboptimal owing to limited awareness and clinical intervention. Acute exacerbations punctuate the progression of COPD in many patients, reducing lung function and increasing the risk of subsequent exacerbations and cardiovascular events that may lead to early death. This narrative review defines and summarises the principles of COPD-associated cardiopulmonary risk, and examines respiratory interventions currently available to modify this risk, as well as providing expert opinion on future approaches to addressing cardiopulmonary risk.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester, M23 9QZ, UK.
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Daiana Stolz
- Clinic of Respiratory Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Chris P Gale
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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Müllerová H, Chan JSK, Heatley H, Carter V, Townend J, Skinner D, Franzén S, Marshall J, Price D. Budesonide/Glycopyrrolate/Formoterol for the Management of COPD in a UK Primary Care Population: Real-World Use and Early Medication Success. Int J Chron Obstruct Pulmon Dis 2024; 19:1153-1166. [PMID: 38813078 PMCID: PMC11134059 DOI: 10.2147/copd.s452624] [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: 12/14/2023] [Accepted: 05/14/2024] [Indexed: 05/31/2024] Open
Abstract
Purpose Real-life research is needed to evaluate the effectiveness of budesonide/glycopyrrolate/formoterol (BGF) in routine COPD primary care management. We assessed the frequency of medication success among patients with COPD who initiated BGF using real-world data. Patients and Methods Patients with a recorded diagnostic COPD code who started BGF with ≥2 prescriptions within 90-days were identified in the UK Optimum Patient Care Research Database and followed from first prescription until censoring at the end of follow-up (180-days), death, leaving database or end of data at 24/10/2022. The primary outcome was medication success at 90-days post-BGF initiation, defined as no major cardiac or respiratory event (ie no complicated COPD exacerbation, hospitalization for any respiratory event, myocardial infarction, new/hospitalized heart failure, and death) and no incidence of pneumonia. Medication success was also assessed at 180-days post-BGF initiation. Overall real-life medication success was claimed if the lower 95% confidence interval (CI) for the proportion of patients meeting the primary outcome was ≥70% (defined a priori). Results Two hundred eighty-five patients were included. Prior to BGF initiation, these patients often had severe airflow obstruction (mean ppFEV1: 54.5%), were highly symptomatic (mMRC ≥2: 77.9% (n = 205/263); mean CAT score: 21.7 (SD 7.8)), with evidence of short-acting β2-agonist (SABA) over-use (≥3 inhalers/year: 62.1%, n=179/285), repeat OCS prescriptions (≥2 courses/year: 33.0%, n = 95/285) and multiple primary care consultations (≥2 visits/year: 61.1%, n = 174/285). Overall, 39.6% of patients (n = 113/285) switched from previous triple therapies. Real-life medication success was achieved by 96.5% of patients (n = 275/285 [95% CI: 93.6, 98.3]) during 90-days treatment with BGF and by 91.8% (n = 169/184 [95% CI: 86.9, 95.4]) of patients at 180-days. The prescribed daily dose of SABA remained stable over the study period. Conclusion The majority of patients initiating BGF experienced real-life medication success reflecting the absence of severe cardiopulmonary events. These benefits were apparent after 90-days of treatment and sustained over 180-days.
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Affiliation(s)
- Hana Müllerová
- Medical Evidence Strategy, Biopharmaceuticals R&I Medical, AstraZeneca, Cambridge, UK
| | | | - Heath Heatley
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - John Townend
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Derek Skinner
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Stefan Franzén
- BPM Evidence Statistics, Biopharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Jonathan Marshall
- Global Medical Affairs, Biopharmaceuticals R&I Medical, AstraZeneca, Cambridge, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Bhatt SP, Rabe KF, Hanania NA, Vogelmeier CF, Bafadhel M, Christenson SA, Papi A, Singh D, Laws E, Patel N, Yancopoulos GD, Akinlade B, Maloney J, Lu X, Bauer D, Bansal A, Abdulai RM, Robinson LB. Dupilumab for COPD with Blood Eosinophil Evidence of Type 2 Inflammation. N Engl J Med 2024. [PMID: 38767614 DOI: 10.1056/nejmoa2401304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Dupilumab, a fully human monoclonal antibody that blocks the shared receptor component for interleukin-4 and interleukin-13, key and central drivers of type 2 inflammation, has shown efficacy and safety in a phase 3 trial involving patients with chronic obstructive pulmonary disease (COPD) and type 2 inflammation and an elevated risk of exacerbation. Whether the findings would be confirmed in a second phase 3 trial was unclear. METHODS In a phase 3, double-blind, randomized trial, we assigned patients with COPD who had a blood eosinophil count of 300 cells per microliter or higher to receive subcutaneous dupilumab (300 mg) or placebo every 2 weeks. The primary end point was the annualized rate of moderate or severe exacerbations. Key secondary end points, analyzed in a hierarchical manner to adjust for multiplicity, included the changes from baseline in the prebronchodilator forced expiratory volume in 1 second (FEV1) at weeks 12 and 52 and in the St. George's Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better quality of life) total score at week 52. RESULTS A total of 935 patients underwent randomization: 470 were assigned to the dupilumab group and 465 to the placebo group. As prespecified, the primary analysis was performed after a positive interim analysis and included all available data for the 935 participants, 721 of whom were included in the analysis at week 52. The annualized rate of moderate or severe exacerbations was 0.86 (95% confidence interval [CI], 0.70 to 1.06) with dupilumab and 1.30 (95% CI, 1.05 to 1.60) with placebo; the rate ratio as compared with placebo was 0.66 (95% CI, 0.54 to 0.82; P<0.001). The prebronchodilator FEV1 increased from baseline to week 12 with dupilumab (least-squares mean change, 139 ml [95% CI, 105 to 173]) as compared with placebo (least-squares mean change, 57 ml [95% CI, 23 to 91]), with a significant least-squares mean difference at week 12 of 82 ml (P<0.001) and at week 52 of 62 ml (P = 0.02). No significant between-group difference was observed in the change in SGRQ scores from baseline to 52 weeks. The incidence of adverse events was similar in the two groups and consistent with the established profile of dupilumab. CONCLUSIONS In patients with COPD and type 2 inflammation as indicated by elevated blood eosinophil counts, dupilumab was associated with fewer exacerbations and better lung function than placebo. (Funded by Sanofi and Regeneron Pharmaceuticals; NOTUS ClinicalTrials.gov number, NCT04456673.).
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Affiliation(s)
- Surya P Bhatt
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Klaus F Rabe
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Nicola A Hanania
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Claus F Vogelmeier
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Mona Bafadhel
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Stephanie A Christenson
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Alberto Papi
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Dave Singh
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Elizabeth Laws
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Naimish Patel
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - George D Yancopoulos
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Bolanle Akinlade
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Jennifer Maloney
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Xin Lu
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Deborah Bauer
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Ashish Bansal
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Raolat M Abdulai
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
| | - Lacey B Robinson
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (S.P.B.); LungenClinic Grosshansdorf (member of the German Center for Lung Research [DZL]), Airway Research Center North (ARCN), Grosshansdorf (K.F.R.), Christian-Albrechts University, DZL, ARCN, Kiel (K.F.R.), and the Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, DZL, Marburg (C.F.V.) - all in Germany; the Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston (N.A.H.); King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London (M.B.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester (D.S.) - both in the United Kingdom; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco (S.A.C.); the Respiratory Medicine Unit, University of Ferrara, S. Anna University Hospital, Ferrara, Italy (A.P.); Sanofi, Bridgewater, NJ (E.L., X.L., D.B.); Sanofi, Cambridge, MA (N.P., R.M.A., L.B.R.); and Regeneron Pharmaceuticals, Tarrytown, NY (G.D.Y., B.A., J.M., A.B.)
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5
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Hippisley-Cox J, Coupland CAC, Bafadhel M, Russell REK, Sheikh A, Brindle P, Channon KM. Development and validation of a new algorithm for improved cardiovascular risk prediction. Nat Med 2024; 30:1440-1447. [PMID: 38637635 PMCID: PMC11108771 DOI: 10.1038/s41591-024-02905-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 03/04/2024] [Indexed: 04/20/2024]
Abstract
QRISK algorithms use data from millions of people to help clinicians identify individuals at high risk of cardiovascular disease (CVD). Here, we derive and externally validate a new algorithm, which we have named QR4, that incorporates novel risk factors to estimate 10-year CVD risk separately for men and women. Health data from 9.98 million and 6.79 million adults from the United Kingdom were used for derivation and validation of the algorithm, respectively. Cause-specific Cox models were used to develop models to predict CVD risk, and the performance of QR4 was compared with version 3 of QRISK, Systematic Coronary Risk Evaluation 2 (SCORE2) and atherosclerotic cardiovascular disease (ASCVD) risk scores. We identified seven novel risk factors in models for both men and women (brain cancer, lung cancer, Down syndrome, blood cancer, chronic obstructive pulmonary disease, oral cancer and learning disability) and two additional novel risk factors in women (pre-eclampsia and postnatal depression). On external validation, QR4 had a higher C statistic than QRISK3 in both women (0.835 (95% confidence interval (CI), 0.833-0.837) and 0.831 (95% CI, 0.829-0.832) for QR4 and QRISK3, respectively) and men (0.814 (95% CI, 0.812-0.816) and 0.812 (95% CI, 0.810-0.814) for QR4 and QRISK3, respectively). QR4 was also more accurate than the ASCVD and SCORE2 risk scores in both men and women. The QR4 risk score identifies new risk groups and provides superior CVD risk prediction in the United Kingdom compared with other international scoring systems for CVD risk.
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Affiliation(s)
- Julia Hippisley-Cox
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK.
| | - Carol A C Coupland
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mona Bafadhel
- King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Richard E K Russell
- King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Aziz Sheikh
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Brindle
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Keith M Channon
- British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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6
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Pang X, Liu X. Immune Dysregulation in Chronic Obstructive Pulmonary Disease. Immunol Invest 2024; 53:652-694. [PMID: 38573590 DOI: 10.1080/08820139.2024.2334296] [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: 04/05/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) is a disease whose incidence increase with age and is characterised by chronic inflammation and significant immune dysregulation. Inhalation of toxic substances cause oxidative stress in the lung tissue as well as airway inflammation, under the recruitment of chemokines, immune cells gathered and are activated to play a defensive role. However, persistent inflammation damages the immune system and leads to immune dysregulation, which is mainly manifested in the reduction of the body's immune response to antigens, and immune cells function are impaired, further destroy the respiratory defensive system, leading to recurrent lower respiratory infections and progressive exacerbation of the disease, thus immune dysregulation play an important role in the pathogenesis of COPD. This review summarizes the changes of innate and adaptive immune-related cells during the pathogenesis of COPD, aiming to control COPD airway inflammation and improve lung tissue remodelling by regulating immune dysregulation, for further reducing the risk of COPD progression and opening new avenues of therapeutic intervention in COPD.
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Affiliation(s)
- Xichen Pang
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
- Department of Gerontal Respiratory Medicine, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoju Liu
- Department of Gerontal Respiratory Medicine, The First Hospital of Lanzhou University, Lanzhou, China
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7
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Agusti A, Lopez-Campos JL, Miravitlles M, Soler-Cataluña JJ, Marin JM, Cosio BG, Alcázar-Navarrete B, Echave-Sustaeta JM, Casanova C, Peces-Barba G, de-Torres JP, Fernandez-Villar A, Ancochea J, Villar-Alvarez F, Roman-Rodriguez M, Molina J, Garcia-Rivero JL, Gonzalez C, Sobradillo P, Faner R, Peña C, Sharma R, Celli BR. Triple Therapy and Clinical Control in B+ COPD Patients: A Pragmatic, Prospective, Randomized Trial. Arch Bronconeumol 2024:S0300-2896(24)00116-9. [PMID: 38729884 DOI: 10.1016/j.arbres.2024.04.008] [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: 03/04/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Treatment with LABA/LAMA is recommended in GOLD B patients. We hypothesized that triple therapy (LABA/LAMA/ICS) will be superior to LABA/LAMA in achieving and maintaining clinical control (CC), a composite outcome that considers both impact and disease stability in a subgroup of GOLD B patients (here termed GOLD B+ patients) characterized by: (1) remaining symptomatic (CAT≥10) despite regular LABA/LAMA therapy; (2) having suffered one moderate exacerbation in the previous year; and (3) having blood eosinophil counts (BEC) ≥150cells/μL. METHODS The ANTES B+ study is a prospective, multicenter, open label, randomized, pragmatic, controlled trial designed to test this hypothesis. It will randomize 1028 B+ patients to continue with their usual LABA/LAMA combination prescribed by their attending physician or to begin fluticasone furoate (FF) 92μg/umeclidinium (UMEC) 55μg/vilanterol (VI) 22μg in a single inhaler q.d. for 12 months. The primary efficacy outcome will be the level of CC achieved. Secondary outcomes include the clinical important deterioration index (CID), annual rate of exacerbations, and FEV1. Exploratory objectives include the interaction of BEC and smoking status, all-cause mortality and proportion of patients on LABA/LAMA arm that switch therapy arms. Safety analysis include adverse events and incidence of pneumonia. RESULTS The first patient was recruited on February 29, 2024; results are expected in the first quarter of 2026. CONCLUSIONS The ANTES B+ study is the first to: (1) explore the efficacy and safety of triple therapy in a population of B+ COPD patients and (2) use a composite index (CC) as the primary result of a COPD trial.
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Affiliation(s)
- Alvar Agusti
- Cátedra Salud Respiratoria, Universidad Barcelona, Institut Respiratori, Clinic Barcelona, FCRB-IDIBAPS, CIBERES, Spain.
| | - José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan Jose Soler-Cataluña
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Neumología, Hospital Arnau de Vilanova-Lliria, Valencia, Spain; Departamento de Medicina, Universitat de València, Spain
| | - Jose Maria Marin
- Respiratory Service, Hospital Universitario Miguel Servet, IISAragón, Zaragoza, Spain
| | - Borja G Cosio
- Department of Respiratory Medicine, Hospital Universitario Son Espases-IdISBa, Universidad de las Islas Baleares, CIBERES, Spain
| | - Bernardino Alcázar-Navarrete
- Servicio de Neumología, Hospital Universitario Virgen de las Nieves, IBS-Granada, Universidad de Granada, CIBERES, Spain
| | | | - Ciro Casanova
- Pulmonary Department - Research Unit, Hospital Universitario Nuestra Señora de La Candelaria, CIBERES, ISCIII, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | | | | | - Alberto Fernandez-Villar
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Neumología, Hospital Álvaro Cunqueiro, Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Julio Ancochea
- Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, CIBER Enfermedades Respiratorias, Madrid, Spain
| | - Felipe Villar-Alvarez
- Pulmonology Department, IIS Fundación Jiménez Díaz, Universidad Autónoma of Madrid, CIBER Enfermedades Respiratorias, Madrid, Spain
| | - Miguel Roman-Rodriguez
- Primary Care Health Service Mallorca, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa) Palma, Universidad de las Islas Baleares, Spain
| | - Jesus Molina
- Centro de Salud Francia, Fuenlabrada, Madrid, Spain; Dirección Asistencial Oeste, Spain
| | | | - Cruz Gonzalez
- Respiratory Department, Hospital Clínico Universitario, Valencia, Spain
| | - Patricia Sobradillo
- Pulmonology Department, Hospital Universitario de Cruces, Barakaldo, Vizcaya, Spain
| | - Rosa Faner
- Biomedicine Department, University of Barcelona, FCRB-IDIBAPS, CIBERES, Barcelona, Spain
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8
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Hawkins NM, Nordon C, Rhodes K, Talukdar M, McMullen S, Ekwaru P, Pham T, Randhawa AK, Sin DD. Heightened long-term cardiovascular risks after exacerbation of chronic obstructive pulmonary disease. Heart 2024; 110:702-709. [PMID: 38182279 PMCID: PMC11103306 DOI: 10.1136/heartjnl-2023-323487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVE To examine the risk of adverse cardiovascular (CV) events following an exacerbation of chronic obstructive pulmonary disease (COPD). METHODS This retrospective cohort study identified patients with COPD using administrative data from Alberta, Canada from 2014 to 2019. Exposure periods were 12 months following moderate or severe exacerbations; the reference period was time preceding a first exacerbation. The primary outcome was the composite of all-cause death or a first hospitalisation for acute coronary syndrome, heart failure (HF), arrhythmia or cerebral ischaemia. Time-dependent Cox regression models estimated covariate-adjusted risks associated with six exposure subperiods following exacerbation. RESULTS Among 1 42 787 patients (mean age 68.1 years and 51.7% men) 61 981 (43.4%) experienced at least one exacerbation and 34 068 (23.9%) died during median follow-up of 64 months. The primary outcome occurred in 43 564 (30.5%) patients with an incidence rate prior to exacerbation of 5.43 (95% CI 5.36 to 5.50) per 100 person-years. This increased to 95.61 per 100 person-years in the 1-7 days postexacerbation (adjusted HR 15.86, 95% CI 15.17 to 16.58) and remained increased for up to 1 year. The risk of both the composite and individual CV events was increased following either a moderate or a severe exacerbation, though greater and more prolonged following severe exacerbation. The highest magnitude of increased risk was observed for HF decompensation (1-7 days, HR 72.34, 95% CI 64.43 to 81.22). CONCLUSION Moderate and severe COPD exacerbations are independent risk factors for adverse CV events, especially HF decompensation. The impact of optimising COPD management on CV outcomes should be evaluated.
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Affiliation(s)
- Nathaniel M Hawkins
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Paul Ekwaru
- Medlior Health Outcomes Research Ltd, Calgary, Alberta, Canada
| | - Tram Pham
- Medlior Health Outcomes Research Ltd, Calgary, Alberta, Canada
| | | | - Don D Sin
- UBC Centre for Heart Lung Innovation and Department of Medicine (Respirology), The University of British Columbia, Vancouver, British Columbia, Canada
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9
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de Miguel-Díez J, Núñez Villota J, Santos Pérez S, Manito Lorite N, Alcázar Navarrete B, Delgado Jiménez JF, Soler-Cataluña JJ, Pascual Figal D, Sobradillo Ecenarro P, Gómez Doblas JJ. Multidisciplinary Management of Patients With Chronic Obstructive Pulmonary Disease and Cardiovascular Disease. Arch Bronconeumol 2024; 60:226-237. [PMID: 38383272 DOI: 10.1016/j.arbres.2024.01.013] [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] [Received: 11/28/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently coexist, increasing the prevalence of both entities and impacting on symptoms and prognosis. CVD should be suspected in patients with COPD who have high/very high risk scores on validated scales, frequent exacerbations, precordial pain, disproportionate dyspnea, or palpitations. They should be referred to cardiology if they have palpitations of unknown cause or angina pain. COPD should be suspected in patients with CVD if they have recurrent bronchitis, cough and expectoration, or disproportionate dyspnea. They should be referred to a pulmonologist if they have rhonchi or wheezing, air trapping, emphysema, or signs of chronic bronchitis. Treatment of COPD in cardiovascular patients should include long-acting muscarinic receptor antagonists (LAMA) or long-acting beta-agonists (LABA) in low-risk or high-risk non-exacerbators, and LAMA/LABA/inhaled corticosteroids in exacerbators who are not controlled with bronchodilators. Cardioselective beta-blockers should be favored in patients with CVD, the long-term need for amiodarone should be assessed, and antiplatelet drugs should be maintained if indicated.
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Affiliation(s)
- Javier de Miguel-Díez
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, Madrid, Spain.
| | - Julio Núñez Villota
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Salud Santos Pérez
- Servicio de Neumología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Nicolás Manito Lorite
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Juan Francisco Delgado Jiménez
- Servicio de Cardiología e Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Medicina, UCM, CIBERCV, Madrid, Spain
| | - Juan José Soler-Cataluña
- Servicio de Neumología, Hospital Arnau de Vilanova-Lliria, Valencia, Spain; Departamento de Medicina, Universitat de València, Valencia, Spain
| | - Domingo Pascual Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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10
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Polman R, Hurst JR, Uysal OF, Mandal S, Linz D, Simons S. Cardiovascular disease and risk in COPD: a state of the art review. Expert Rev Cardiovasc Ther 2024; 22:177-191. [PMID: 38529639 DOI: 10.1080/14779072.2024.2333786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular diseases (CVD) commonly co-exist. Outcomes of people living with both conditions are poor in terms of symptom burden, receiving evidence-based treatment and mortality. Increased understanding of the underlying mechanisms may help to identify treatments to relieve this disease burden. This narrative review covers the overlap of COPD and CVD with a focus on clinical presentation, mechanisms, and interventions. Literature up to December 2023 are cited. AREAS COVERED 1. What is COPD 2. The co-existence of COPD and cardiovascular disease 3. Mechanisms of cardiovascular disease in COPD. 4. Populations with COPD are at risk of CVD 5. Complexity in the co-diagnosis of COPD in those with cardiovascular disease. 6. Therapy for COPD and implications for cardiovascular events and risk. 7. Cardiovascular risk and exacerbations of COPD. 8. Pro-active identification and management of CV risk in COPD. EXPERT OPINION The prospective identification of co-morbid COPD in CVD patients and of CVD and CV risk in people with COPD is crucial for optimizing clinical outcomes. This includes the identification of novel treatment targets and the design of clinical trials specifically designed to reduce the cardiovascular burden and mortality associated with COPD. Databases searched: Pubmed, 2006-2023.
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Affiliation(s)
- Ricardo Polman
- Department of Respiratory Medicine, Maastricht UMC+, Maastricht, the Netherlands
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | - Swapna Mandal
- UCL Respiratory, University College London, London, UK
| | - Dominik Linz
- Faculty of Health and Medical Sciences, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Sami Simons
- Department of Respiratory Medicine, Maastricht UMC+, Maastricht, the Netherlands
- Department of Respiratory Medicine, Research Institute of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
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11
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Suissa S. Observational studies to emulate randomized trials: Some real-world barriers. Br J Clin Pharmacol 2024; 90:1193-1198. [PMID: 38225188 DOI: 10.1111/bcp.15998] [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] [Received: 11/13/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/17/2024] Open
Abstract
The randomized controlled trial (RCT) forms the basis for drug approval by regulatory agencies. Observational studies using existing data from healthcare databases now also provide real-world evidence (RWE) in regulatory decision-making. Several initiatives are assessing the value of RWE by conducting observational studies that emulate published RCTs. While many RCTs are straightforward to emulate, others are challenging. We describe three RCT design aspects that pose challenges for observational studies. First are trials that enrol already treated subjects who must discontinue these treatments at the time of randomization, which can distort the comparison with observational studies. Second is the inclusion of a run-in phase, especially to exclude non-compliant subjects from the trial. Third are trials that evaluate the effect of weaning off treatment. In conclusion, future randomized trials that aim to be emulated by observational studies could consider study designs that allow emulation and thus provide valid and complementary RWE.
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, and Department of Epidemiology and Biostatistics, McGill University, Montreal, Québec, Canada
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12
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Hu Y, Yan R, Yin X, Gong E, Xin X, Gao A, Shi X, Wang J, Xue H, Feng L, Zhang J. Effectiveness of Multifaceted Strategies to Increase Influenza Vaccination Uptake: A Cluster Randomized Trial. JAMA Netw Open 2024; 7:e243098. [PMID: 38526493 DOI: 10.1001/jamanetworkopen.2024.3098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
Importance Influenza vaccination rates remain low among primary school students and vary by school in Beijing, China. Theory-informed, multifaceted strategies are needed to improve influenza vaccination uptake. Objective To evaluate the effectiveness of multifaceted strategies in improving influenza vaccination uptake among primary school students. Design, Setting, and Participants This cluster randomized trial was conducted from September 2022 to May 2023 across primary schools in Beijing, China. Schools were allocated randomly in a 1:1 ratio to multifaceted strategies or usual practice. Schools were deemed eligible if the vaccination rates in the 2019 to 2020 season fell at or below the district-wide average for primary schools. Eligible participants included students in grades 2 and 3 with no medical contraindications for influenza vaccination. Intervention The multifaceted strategies intervention involved system-level planning and coordination (eg, developing an implementation blueprint, building social norms, and enhancing supervision), school-level training and educating school implementers (eg, conducting a 1-hour training and developing educational materials), and individual-level educating and reminding students and parents (eg, conducting educational activities and sending 4 reminders about vaccination). Main Outcomes and Measures The primary outcomes were influenza vaccination uptake at school reported by school clinicians as well as overall vaccine uptake either at school or outside of school as reported by parents at 3 months. Generalized linear mixed models were used for analysis. Results A total of 20 schools were randomized. One intervention school and 2 control schools did not administer vaccination on school grounds due to COVID-19, resulting in a total of 17 schools (9 intervention and 8 control). There was a total of 1691 students aged 7 to 8 years (890 male [52.6%]; 801 female [47.4%]) including 915 in the intervention group and 776 in the control group. Of all participants, 848 (50.1%) were in grade 2, and 1209 (71.5%) were vaccinated in the 2021 to 2022 season. Participants in the intervention and control groups shared similar characteristics. At follow-up, of the 915 students in the intervention group, 679 (74.5%) received a vaccination at school, and of the 776 students in the control group, 556 (71.7%) received a vaccination at school. The overall vaccination rates were 76.0% (695 of 915 students) for the intervention group and 71.3% (553 of 776 students) for the control group. Compared with the control group, there was significant improvement of vaccination uptake at school (odds ratio, 1.40; 95% CI, 1.06-1.85; P = .02) and overall uptake (odds ratio, 1.49; 95% CI, 1.12-1.99; P = .01) for the intervention group. Conclusions and Relevance In this study, multifaceted strategies showed modest effectiveness in improving influenza vaccination uptake among primary school students, which provides a basis for the implementation of school-located vaccination programs of other vaccines in China, and in other countries with comparable programs. Trial registration Chinese Clinical Trial Registry: ChiCTR2200062449.
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Affiliation(s)
- Yiluan Hu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ruijie Yan
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xuejun Yin
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Enying Gong
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin Xin
- Faculty of Psychology, Beijing Normal University, Beijing, China
| | - Aiyu Gao
- Dongcheng Primary and Secondary School Health Care Center, Beijing, China
| | - Xiaoyan Shi
- Dongcheng Primary and Secondary School Health Care Center, Beijing, China
| | - Jing Wang
- Department of Infectious Disease, Dongcheng Center for Disease Control and Prevention, Beijing, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, California
| | - Luzhao Feng
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Juan Zhang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
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13
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Bergantini L, Baker J, Bossios A, Braunstahl GJ, Conemans LH, Lombardi F, Mathioudakis AG, Pobeha P, Ricciardolo FLM, Prada Romero LP, Schleich F, Snelgrove RJ, Trinkmann F, Uller L, Beech A. ERS International Congress 2023: highlights from the Airway Diseases Assembly. ERJ Open Res 2024; 10:00891-2023. [PMID: 38529346 PMCID: PMC10962455 DOI: 10.1183/23120541.00891-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 03/27/2024] Open
Abstract
In this review, early career and senior members of Assembly 5 (Airway Diseases, Asthma, COPD and Chronic Cough) present key recent findings pertinent to airway diseases that were presented during the European Respiratory Society International Congress 2023 in Milan, Italy, with a particular focus on asthma, COPD, chronic cough and bronchiectasis. During the congress, an increased number of symposia, workshops and abstract presentations were organised. In total, 739 abstracts were submitted for Assembly 5 and the majority of these were presented by early career members. These data highlight the increased interest in this group of respiratory diseases.
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Affiliation(s)
- Laura Bergantini
- Respiratory Disease Unit, Department of Medical Sciences, Surgery, and Neurosciences, University of Siena, Siena, Italy
| | - James Baker
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Apostolos Bossios
- Karolinska Severe Asthma Center, Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gert-Jan Braunstahl
- Franciscus Gasthuis and Vlietland Hospital, Rotterdam, The Netherlands
- Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Francesco Lombardi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alexander G. Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Pavol Pobeha
- Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Slovakia
| | - Fabio Luigi Massimo Ricciardolo
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- Institute of Translational Pharmacology, National Research Council (IFT-CNR), Palermo, Italy
| | | | - Florence Schleich
- Respiratory Medicine, CHU Sart-Tilman B35, University of Liège, GIGA I3, Liège, Belgium
| | | | - Frederik Trinkmann
- Department of Pneumology and Critical Care Medicine, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany
- Department of Biomedical Informatics, Center for Preventive Medicine and Digital Health, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Lena Uller
- Department of Experimental Medical Science, Unit of Respiratory Immunopharmacology, Lund University, Lund, Sweden
| | - Augusta Beech
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
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14
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Zader JA, Jörres RA, Mayer I, Alter P, Bals R, Watz H, Mertsch P, Rabe KF, Herth F, Trudzinski FC, Welte T, Kauczor HU, Behr J, Walter J, Vogelmeier CF, Kahnert K. Effects of triple therapy on disease burden in patients of GOLD groups C and D: results from the observational COPD cohort COSYCONET. BMC Pulm Med 2024; 24:103. [PMID: 38424530 PMCID: PMC10905841 DOI: 10.1186/s12890-024-02902-4] [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] [Received: 10/06/2023] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Randomized controlled trials described beneficial effects of inhaled triple therapy (LABA/LAMA/ICS) in patients with chronic obstructive pulmonary disease (COPD) and high risk of exacerbations. We studied whether such effects were also detectable under continuous treatment in a retrospective observational setting. METHODS Data from baseline and 18-month follow-up of the COPD cohort COSYCONET were used, including patients categorized as GOLD groups C/D at both visits (n = 258). Therapy groups were defined as triple therapy at both visits (triple always, TA) versus its complement (triple not always, TNA). Comparisons were performed via multiple regression analysis, propensity score matching and inverse probability weighting to adjust for differences between groups. For this purpose, variables were divided into predictors of therapy and outcomes. RESULTS In total, 258 patients were eligible (TA: n = 162, TNA: n = 96). Without adjustments, TA patients showed significant (p < 0.05) impairments regarding lung function, quality of life and symptom burden. After adjustments, most differences in outcomes were no more significant. Total direct health care costs were reduced but still elevated, with inpatient costs much reduced, while costs of total and respiratory medication only slightly changed. CONCLUSION Without statistical adjustment, patients with triple therapy showed multiple impairments as well as elevated treatment costs. After adjusting for differences between treatment groups, differences were reduced. These findings are compatible with beneficial effects of triple therapy under continuous, long-term treatment, but also demonstrate the limitations encountered in the comparison of controlled intervention studies with observational studies in patients with severe COPD using different types of devices and compounds.
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Affiliation(s)
- Jennifer A Zader
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Center Munich (CPC-M), Ludwig-Maximilians-Universität München, Munich, Germany
| | - Imke Mayer
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
- PreMeDICaL, Inria Montpellier, IDESP, Montpellier, France
| | - Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, German Center for Lung Research (DZL), University Medical Center Giessen and Marburg, Philipps-University Marburg, Germany, Marburg, Germany
| | - Robert Bals
- Department of Internal Medicine V - Pulmonology, Allergology, Respiratory Intensive Care Medicine, Saarland University Hospital, Kirrberger Straße 1, 66424, Homburg, Germany
- Helmholtz Centre for Infection Research (HZI), Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Saarland University Campus, 66123, Saarbrücken, Germany
| | - Henrik Watz
- Member of the German Center for Lung Research, Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Woehrendamm 80, 22927, Grosshansdorf, Germany
| | - Pontus Mertsch
- Department of Medicine V, Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), University Hospital, LMU Munich, Ziemssenstr.1, 80336, Munich, Germany
| | - Klaus F Rabe
- Member of the German Center for Lung Research, Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Woehrendamm 80, 22927, Grosshansdorf, Germany
- Faculty of Medicine, Christian-Albrechts-Universität Zu Kiel, 24098, Kiel, Germany
| | - Felix Herth
- Thoraxklinik-Heidelberg gGmbH, Röntgenstraße 1, 69126, Heidelberg, Germany
- Member of the German Center for Lung Research, Translational Lung Research Centre Heidelberg (TLRC), Heidelberg, Germany
| | - Franziska C Trudzinski
- Thoraxklinik-Heidelberg gGmbH, Röntgenstraße 1, 69126, Heidelberg, Germany
- Member of the German Center for Lung Research, Translational Lung Research Centre Heidelberg (TLRC), Heidelberg, Germany
| | - Tobias Welte
- Department of Pneumology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Hans-Ulrich Kauczor
- Department of Diagnostic & Interventional Radiology, University Hospital of Heidelberg, Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Behr
- Department of Medicine V, Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), University Hospital, LMU Munich, Ziemssenstr.1, 80336, Munich, Germany
| | - Julia Walter
- Department of Medicine V, Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), University Hospital, LMU Munich, Ziemssenstr.1, 80336, Munich, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, German Center for Lung Research (DZL), University Medical Center Giessen and Marburg, Philipps-University Marburg, Germany, Marburg, Germany
| | - Kathrin Kahnert
- Department of Medicine V, Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), University Hospital, LMU Munich, Ziemssenstr.1, 80336, Munich, Germany.
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15
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Santus P, Di Marco F, Braido F, Contoli M, Corsico AG, Micheletto C, Pelaia G, Radovanovic D, Rogliani P, Saderi L, Scichilone N, Tanzi S, Vella M, Boarino S, Sotgiu G, Solidoro P. Exacerbation Burden in COPD and Occurrence of Mortality in a Cohort of Italian Patients: Results of the Gulp Study. Int J Chron Obstruct Pulmon Dis 2024; 19:607-618. [PMID: 38444551 PMCID: PMC10913796 DOI: 10.2147/copd.s446636] [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: 10/26/2023] [Accepted: 01/28/2024] [Indexed: 03/07/2024] Open
Abstract
Objective To describe the burden of moderate to severe exacerbations and all-cause mortality; the secondary objectives were to analyze treatment patterns and changes over follow-up. Design Observational, multicenter, retrospective, cohort study with a three year follow-up period. Setting Ten Italian academic secondary- and tertiary-care centers. Participants Patients with a confirmed diagnosis of COPD referring to the outpatient clinics of the participating centers were retrospectively recruited. Primary and Secondary Outcome Measures Annualized frequency of moderate and severe exacerbations stratified by exacerbation history prior to study enrollment. Patients were classified according to airflow obstruction, GOLD risk categories, and divided in 4 groups: A = no exacerbations; B = 1 moderate exacerbation; C = 1 severe exacerbation; D = ≥2 moderate and/or severe exacerbations. Overall all-cause mortality stratified by age, COPD category, and COPD therapy. A logistic regression model assessed the association of clinical characteristics with mortality. Results 1111 patients were included (73% males), of which 41.5% had a history of exacerbations. As expected, the proportion of patients experiencing ≥1 exacerbation during follow-up increased according to pre-defined study risk categories (B: 79%, C: 84%, D: 97.4%). Overall, by the end of follow-up, 45.5% of patients without a history of exacerbation experienced an exacerbation (31% of which severe), and 13% died. Deceased patients were significantly older, more obstructed and hyperinflated, and more frequently active smokers compared with survivors. Severe exacerbations were more frequent in patients that died (23.5%, vs 10.2%; p-value: 0.002). Chronic heart failure and ischemic heart disease were the only comorbidities associated with a higher odds ratio (OR) for death (OR: 2.2, p-value: 0.001; and OR: 1.9, p-value: 0.007). Treatment patterns were similar in patients that died and survivors. Conclusion Patients with a low exacerbation risk are exposed to a significant future risk of moderate/severe exacerbations. Real life data confirm the strong association between mortality and cardiovascular comorbidities in COPD.
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Affiliation(s)
- Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università degli Studi di Milano Pneumology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Fulvio Braido
- Department of Internal Medicine (DiMI), Respiratory Unit for Continuity of Care, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Marco Contoli
- Department of Translational Medicine, Respiratory Section, University of Ferrara, Ferrara, Italy
| | - Angelo Guido Corsico
- Department of Medical Sciences and Infective Diseases, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and University of Pavia Medical School, Pavia, Italy
| | - Claudio Micheletto
- Cardio-Thoracic Department, Respiratory Unit, University Integrated Hospital, Verona, Italy
| | - Girolamo Pelaia
- Dipartimento di Scienze della Salute, Università Magna Graecia, Catanzaro, Italy
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome ”Tor Vergata”, Division of Respiratory Medicine, University Hospital ”Tor Vergata”, Rome, Italy
| | - Laura Saderi
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Nicola Scichilone
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | | | | | | | - Giovanni Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Paolo Solidoro
- Department of Medical Sciences, University of Turin, S.C. Pneumologia, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
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16
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McCormack M, Paczkowski R, Gronroos NN, Noorduyn SG, Lee L, Veeranki P, Johnson MG, Igboekwe E, Kahle-Wrobleski K, Panettieri R. Outcomes of Patients with COPD Treated with ICS/LABA Before and After Initiation of Single-Inhaler Triple Therapy with Fluticasone Furoate/Umeclidinium/Vilanterol (FF/UMEC/VI). Adv Ther 2024; 41:1245-1261. [PMID: 38310193 PMCID: PMC10879256 DOI: 10.1007/s12325-023-02776-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/18/2023] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Triple therapy (fluticasone furoate/umeclidinium/vilanterol; FF/UMEC/VI) has been shown to improve symptoms and reduce exacerbations in patients with chronic obstructive pulmonary disease (COPD) and a history of exacerbations. This real-world study compared exacerbation rates and healthcare resource utilization (HCRU) before and after initiation of FF/UMEC/VI in patients with COPD previously treated with inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA). METHODS This retrospective cohort study included commercial and Medicare Advantage with Part D administrative claims data from September 01, 2016, to March 31, 2020, of patients diagnosed with COPD. The index date was the date of the first FF/UMEC/VI claim (September 2017-March 2019). The 12 months prior to index (baseline) were used to assess patient characteristics and outcomes; the 12 months following index (follow-up) were used to assess study outcomes. All patients had ≥ 30 consecutive days' supply of any ICS/LABA dual therapy during the 12 months prior to FF/UMEC/VI initiation. Subgroup analyses included patients with ≥ 30 consecutive days' supply of budesonide/formoterol (BUD/FORM) during baseline. Analyses of patients with ≥ 1 COPD exacerbation during baseline were reported as well. RESULTS The overall population included 1449 patients (mean age 70.75 years; 54.18% female), of whom 540 were patients in the BUD/FORM subgroup. Significantly fewer patients experienced any exacerbation during follow-up versus baseline (overall population 53.49% vs 62.59%; p < 0.001; BUD/FORM subgroup 55.00% vs 62.41%; p = 0.004). Effects on exacerbation reduction were more pronounced among patients with ≥ 1 exacerbation during baseline. Lower COPD-related HCRU was observed during the follow-up compared with baseline for both the overall population and the BUD/FORM subgroup. CONCLUSION Patients with COPD treated with ICS/LABA during baseline, including patients specifically treated with BUD/FORM and those with a history of ≥ 1 exacerbation, had fewer COPD exacerbations and lower COPD-related HCRU after initiating FF/UMEC/VI.
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Affiliation(s)
- Meredith McCormack
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Rosirene Paczkowski
- Value Evidence and Outcomes, R&D Global Medical, GSK, Collegeville, PA, 19426-0989, USA.
| | - Noelle N Gronroos
- Health Economics and Outcomes Research, Optum, Eden Prairie, MN, USA
| | - Stephen G Noorduyn
- Global Value Evidence and Outcomes, GSK, Mississauga, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lydia Lee
- Value Evidence and Outcomes, R&D Global Medical, GSK, Collegeville, PA, 19426-0989, USA
- Center for Health Outcomes, Policy and Economics, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Phani Veeranki
- Health Economics and Outcomes Research, Optum, Eden Prairie, MN, USA
| | - Mary G Johnson
- Health Economics and Outcomes Research, Optum, Eden Prairie, MN, USA
| | | | | | - Reynold Panettieri
- Rutgers Institute for Translational Medicine and Science, New Brunswick, NJ, USA
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17
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Reid F, Singh D, Albayaty M, Moate R, Jimenez E, Sadiq MW, Howe D, Gavala M, Killick H, Williams A, Krishnan S, Godwood A, Shukla A, Hewitt L, Lei A, Kell C, Pandya H, Newcombe P, White N, Scott IC, Cohen ES. A Randomized Phase I Study of the Anti-Interleukin-33 Antibody Tozorakimab in Healthy Adults and Patients With Chronic Obstructive Pulmonary Disease. Clin Pharmacol Ther 2024; 115:565-575. [PMID: 38115209 DOI: 10.1002/cpt.3147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023]
Abstract
Tozorakimab is a human monoclonal antibody that neutralizes interleukin (IL)-33. IL-33 is a broad-acting epithelial "alarmin" cytokine upregulated in lung tissue of patients with chronic obstructive pulmonary disease (COPD). This first-in-human, phase I, randomized, double-blind, placebo-controlled study (NCT03096795) evaluated the safety, tolerability, pharmacokinetics (PKs), immunogenicity, target engagement, and pharmacodynamics (PDs) of tozorakimab. This was a 3-part study. In part 1, 56 healthy participants with a history of mild atopy received single escalating doses of either intravenous or subcutaneous tozorakimab or placebo. In part 2, 24 patients with mild COPD received multiple ascending doses of subcutaneous tozorakimab or placebo. In part 3, 8 healthy Japanese participants received a single intravenous dose of tozorakimab or placebo. The safety data collected included treatment-emergent adverse events (TEAEs), vital signs, and clinical laboratory parameters. Biological samples for PKs, immunogenicity, target engagement, and PD biomarker analyses were collected. No meaningful differences in the frequencies of TEAEs were observed between the tozorakimab and placebo arms. Three tozorakimab-treated participants with COPD experienced treatment-emergent serious adverse events. Subcutaneous or intravenous tozorakimab demonstrated linear, time-independent PKs with a mean half-life of 11.7-17.3 days. Treatment-emergent anti-drug antibody frequency was low. Engagement of tozorakimab with endogenous IL-33 in serum and nasal airways was demonstrated. Tozorakimab significantly reduced serum IL-5 and IL-13 levels in patients with COPD compared with placebo. Overall, tozorakimab was well tolerated, with a linear, time-independent serum PK profile. Additionally, biomarker studies demonstrated proof of mechanism. Overall, these data support the further clinical development of tozorakimab in COPD and other inflammatory diseases.
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Affiliation(s)
- Fred Reid
- Clinical Development, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Muna Albayaty
- Parexel International, Early Phase Clinical Unit, Northwick Park Hospital, Harrow, UK
| | - Rachel Moate
- Early Biostatistics and Statistical Innovation, Data Science and AI, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Eulalia Jimenez
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Barcelona, Spain
| | - Muhammad Waqas Sadiq
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - David Howe
- Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Monica Gavala
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Helen Killick
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Adam Williams
- Integrated Bioanalysis, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Surekha Krishnan
- GxP Testing Lab, Integrated Bioanalysis, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Alex Godwood
- Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Animesh Shukla
- GxP Testing Lab, Integrated Bioanalysis, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Lisa Hewitt
- GxP Testing Lab, Integrated Bioanalysis, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Alejhandra Lei
- Patient Safety BioPharma, Chief Medical Office, R&D, AstraZeneca, Barcelona, Spain
| | - Chris Kell
- Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Hitesh Pandya
- Clinical Development, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Paul Newcombe
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Nicholas White
- Integrated Bioanalysis, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Ian C Scott
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - E Suzanne Cohen
- Bioscience Asthma and Skin Immunity, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
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18
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Melani AS, Croce S, Fabbri G, Messina M, Bargagli E. Inhaled Corticosteroids in Subjects with Chronic Obstructive Pulmonary Disease: An Old, Unfinished History. Biomolecules 2024; 14:195. [PMID: 38397432 PMCID: PMC10887366 DOI: 10.3390/biom14020195] [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] [Received: 12/11/2023] [Revised: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the major causes of disability and death. Maintenance use of inhaled bronchodilator(s) is the cornerstone of COPD pharmacological therapy, but inhaled corticosteroids (ICSs) are also commonly used. This narrative paper reviews the role of ICSs as maintenance treatment in combination with bronchodilators, usually in a single inhaler, in stable COPD subjects. The guidelines strongly recommend the addition of an ICS in COPD subjects with a history of concomitant asthma or as a step-up on the top of dual bronchodilators in the presence of hospitalization for exacerbation or at least two moderate exacerbations per year plus high blood eosinophil counts (≥300/mcl). This indication would only involve some COPD subjects. In contrast, in real life, triple inhaled therapy is largely used in COPD, independently of symptoms and in the presence of exacerbations. We will discuss the results of recent randomized controlled trials that found reduced all-cause mortality with triple inhaled therapy compared with dual inhaled long-acting bronchodilator therapy. ICS use is frequently associated with common local adverse events, such as dysphonia, oral candidiasis, and increased risk of pneumonia. Other side effects, such as systemic toxicity and unfavorable changes in the lung microbiome, are suspected mainly at higher doses of ICS in elderly COPD subjects with comorbidities, even if not fully demonstrated. We conclude that, contrary to real life, the use of ICS should be carefully evaluated in stable COPD patients.
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Affiliation(s)
- Andrea S. Melani
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (S.C.); (G.F.); (M.M.); (E.B.)
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19
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Vogelmeier CF, Friedrich FW, Timpel P, Kossack N, Diesing J, Pignot M, Abram M, Halbach M. Impact of COPD on mortality: An 8-year observational retrospective healthcare claims database cohort study. Respir Med 2024; 222:107506. [PMID: 38151176 DOI: 10.1016/j.rmed.2023.107506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality. Here we present a large observational study on the association of COPD and exacerbations with mortality (AvoidEx Mortality). METHODS A real-world, observational cohort study with longitudinal analyses of German healthcare claims data in patients ≥40 years of age with a COPD diagnosis from 2011 to 2018 (n = 250,723) was conducted. Patients entered the cohort (index date) upon the first COPD diagnosis. To assess the impact of COPD on all-cause death, a propensity score-matched control group of non-COPD patients was constructed. The number and severity of exacerbations during a 12-month pre-index period were used to form subgroups. For each exacerbation subgroup the exacerbations during 12 months prior to death were analysed. RESULTS COPD increases the all-cause mortality risk by almost 60% (HR 1.57 (95% CI 1.55-1.59)) in comparison to matched non-COPD controls, when controlling for other baseline covariates. The cumulative risk of death after 8 years was highest in patients with a history of more than one moderate or severe exacerbation. Among all deceased COPD patients, 17.2% had experienced a severe, and 34.8% a moderate exacerbation, within 3 months preceding death. Despite increasing exacerbation rates towards death, more than the half of patients were not receiving any recommended pharmacological COPD therapy in the year before death. CONCLUSION Our study illustrates the impact of COPD on mortality risk and highlights the need for consequent COPD management comprising exacerbation assessment and treatment.
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Affiliation(s)
- Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, German Center for Lung Research (DZL), Baldingerstraße, 35033, Marburg, Hessen, Germany
| | | | - Patrick Timpel
- WIG2 GmbH Scientific Institute for Health Economics and Health System Research, Markt 8, 04109, Leipzig, Sachsen, Germany
| | - Nils Kossack
- WIG2 GmbH Scientific Institute for Health Economics and Health System Research, Markt 8, 04109, Leipzig, Sachsen, Germany
| | - Joanna Diesing
- WIG2 GmbH Scientific Institute for Health Economics and Health System Research, Markt 8, 04109, Leipzig, Sachsen, Germany
| | - Marc Pignot
- ZEG - Center for Epidemiology and Health Research Berlin GmbH, Invalidenstraße 115, 10115, Berlin, Germany
| | - Melanie Abram
- AstraZeneca GmbH, Friesenweg 26, 22763, Hamburg, Germany
| | - Marija Halbach
- AstraZeneca GmbH, Friesenweg 26, 22763, Hamburg, Germany.
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20
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Chen Y, Li Z, Ji G, Wang S, Mo C, Ding B. Lung regeneration: diverse cell types and the therapeutic potential. MedComm (Beijing) 2024; 5:e494. [PMID: 38405059 PMCID: PMC10885188 DOI: 10.1002/mco2.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
Lung tissue has a certain regenerative ability and triggers repair procedures after injury. Under controllable conditions, lung tissue can restore normal structure and function. Disruptions in this process can lead to respiratory system failure and even death, causing substantial medical burden. The main types of respiratory diseases are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and acute respiratory distress syndrome (ARDS). Multiple cells, such as lung epithelial cells, endothelial cells, fibroblasts, and immune cells, are involved in regulating the repair process after lung injury. Although the mechanism that regulates the process of lung repair has not been fully elucidated, clinical trials targeting different cells and signaling pathways have achieved some therapeutic effects in different respiratory diseases. In this review, we provide an overview of the cell type involved in the process of lung regeneration and repair, research models, and summarize molecular mechanisms involved in the regulation of lung regeneration and fibrosis. Moreover, we discuss the current clinical trials of stem cell therapy and pharmacological strategies for COPD, IPF, and ARDS treatment. This review provides a reference for further research on the molecular and cellular mechanisms of lung regeneration, drug development, and clinical trials.
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Affiliation(s)
- Yutian Chen
- The Department of Endovascular SurgeryThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan UniversityChengduChina
| | - Zhen Li
- The Department of Endovascular SurgeryThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Gaili Ji
- Department of GynecologyThe Third Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Shaochi Wang
- Department of Translational MedicineThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Chunheng Mo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan UniversityChengduChina
| | - Bi‐Sen Ding
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan UniversityChengduChina
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Mariniello DF, D’Agnano V, Cennamo D, Conte S, Quarcio G, Notizia L, Pagliaro R, Schiattarella A, Salvi R, Bianco A, Perrotta F. Comorbidities in COPD: Current and Future Treatment Challenges. J Clin Med 2024; 13:743. [PMID: 38337438 PMCID: PMC10856710 DOI: 10.3390/jcm13030743] [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: 12/15/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition, primarily characterized by the presence of a limited airflow, due to abnormalities of the airways and/or alveoli, that often coexists with other chronic diseases such as lung cancer, cardiovascular diseases, and metabolic disorders. Comorbidities are known to pose a challenge in the assessment and effective management of COPD and are also acknowledged to have an important health and economic burden. Local and systemic inflammation have been proposed as having a potential role in explaining the association between COPD and these comorbidities. Considering that the number of patients with COPD is expected to rise, understanding the mechanisms linking COPD with its comorbidities may help to identify new targets for therapeutic purposes based on multi-dimensional assessments.
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Affiliation(s)
- Domenica Francesca Mariniello
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Vito D’Agnano
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Donatella Cennamo
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Stefano Conte
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Gianluca Quarcio
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Luca Notizia
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Raffaella Pagliaro
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Angela Schiattarella
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Rosario Salvi
- U.O.C. Chirurgia Toracica, Azienda Ospedaliera “S.G. Moscati”, 83100 Avellino, Italy;
| | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
| | - Fabio Perrotta
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (D.F.M.); (V.D.); (D.C.); (S.C.); (G.Q.); (L.N.); (R.P.); (A.S.); (A.B.)
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22
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Lee HJ, Lee JK, Park TY, Heo EY, Kim DK, Lee HW. Clinical outcomes of long-term inhaled combination therapies in patients with bronchiectasis and airflow obstruction. BMC Pulm Med 2024; 24:49. [PMID: 38263115 PMCID: PMC10804611 DOI: 10.1186/s12890-024-02867-4] [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] [Received: 07/27/2023] [Accepted: 01/17/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Few studies have reported which inhaled combination therapy, either bronchodilators and/or inhaled corticosteroids (ICSs), is beneficial in patients with bronchiectasis and airflow obstruction. Our study compared the efficacy and safety among different inhaled combination therapies in patients with bronchiectasis and airflow obstruction. METHODS Our retrospective study analyzed the patients with forced expiratory volume in 1 s (FEV1)/forced vital capacity < 0.7 and radiologically confirmed bronchiectasis in chest computed tomography between January 2005 and December 2021. The eligible patients underwent baseline and follow-up spirometric assessments. The primary endpoint was the development of a moderate-to-severe exacerbation. The secondary endpoints were the change in the annual FEV1 and the adverse events. Subgroup analyses were performed according to the blood eosinophil count (BEC). RESULTS Among 179 patients, the ICS/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA), ICS/LABA, and LABA/LAMA groups were comprised of 58 (32.4%), 52 (29.1%), and 69 (38.5%) patients, respectively. ICS/LABA/LAMA group had a higher severity of bronchiectasis and airflow obstruction, than other groups. In the subgroup with BEC ≥ 300/uL, the risk of moderate-to-severe exacerbation was lower in the ICS/LABA/LAMA group (adjusted HR = 0.137 [95% CI = 0.034-0.553]) and the ICS/LABA group (adjusted HR = 0.196 [95% CI = 0.045-0.861]) compared with the LABA/LAMA group. The annual FEV1 decline rate was significantly worsened in the ICS/LABA group compared to the LABA/LAMA group (adjusted β-coefficient=-197 [95% CI=-307--87]) in the subgroup with BEC < 200/uL. CONCLUSION In patients with bronchiectasis and airflow obstruction, the use of ICS/LABA/LAMA and ICS/LABA demonstrated a reduced risk of exacerbation compared to LABA/LAMA therapy in those with BEC ≥ 300/uL. Conversely, for those with BEC < 200/uL, the use of ICS/LABA was associated with an accelerated decline in FEV1 in comparison to LABA/LAMA therapy. Further assessment of BEC is necessary as a potential biomarker for the use of ICS in patients with bronchiectasis and airflow obstruction.
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Affiliation(s)
- Hyo Jin Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jung-Kyu Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Tae Yeon Park
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Eun Young Heo
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Deog Kyeom Kim
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Hyun Woo Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, South Korea.
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Price D, Henley W, Cançado JED, Fabbri LM, Kerstjens HAM, Papi A, Roche N, Şen E, Singh D, Vogelmeier CF, Nudo E, Carter V, Skinner D, Vella R, Soriano JB, Kots M, Georges G. Risk of Pneumonia in Patients with COPD Initiating Fixed Dose Inhaled Corticosteroid (ICS) / Long-Acting Bronchodilator (LABD) Formulations Containing Extrafine Beclometasone Dipropionate versus Patients Initiating LABD Without ICS. Pragmat Obs Res 2024; 15:1-16. [PMID: 38274639 PMCID: PMC10807314 DOI: 10.2147/por.s438031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024] Open
Abstract
Background Combined ICS and long-acting bronchodilators (LABD) more effectively reduce COPD exacerbations than LABD therapy alone. Corticosteroid-related adverse effects, including pneumonia, limit ICS use. Previous data suggest this risk is lower for extrafine beclometasone (ef-BDP). We compared pneumonia risk among new users of fixed dose ICS/LABD formulations containing ef-BDP, versus patients initiating LABD without any ICS. Methods A propensity-matched historical cohort study design used data from OPCRD. COPD patients with ≥1 year of continuous data who initiated LABD or ICS/LABD formulations containing ef-BDP were matched. Primary outcome was time to pneumonia event, as treated, using either sensitive (physician diagnosed) or specific (physician diagnosed and x-ray or hospital admission confirmed) definitions, with non-inferiority boundary of 15%. Results 23,898 COPD patients were matched, who were 68±11 years, 54.3% male and 56% current-smokers, while 43% were former-smokers. Initiation of ef-BDP/LABD was not associated with an increased risk of pneumonia versus LABD, for either a sensitive 0.89 (0.78-1.02), P = 0.08 or a specific 0.91 (0.78-1.05), P = 0.18 definition of pneumonia. The probability of remaining pneumonia free 1-year after ef-BDP/LABD was 98.4%, which was comparable to LABD at 97.7%, and was sustained up to 6 years of observation; non-inferiority criterion was met for both definitions. Initiation of ef-BDP/LABD was also associated with a reduced risk of developing LRTIs in the propensity matched cohort. Conclusion Risk of pneumonia when using ICS for the management of COPD reported in several randomised controlled trials may not be relevant with ef-BDP in a diverse real-world clinical population.
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Affiliation(s)
- David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - William Henley
- Observational and Pragmatic Research Institute, Singapore
- Health Statistics Group, Department of Health and Community Sciences, University of Exeter Medical School, Exeter, UK
| | | | - Leonardo M Fabbri
- Respiratory Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen and University Medical Centre Groningen, and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, the Netherlands
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP-Centre University of Paris, Cochin Hospital and Institute (UMR1016), Paris, France
| | - Elif Şen
- Department of Pulmonary Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Claus F Vogelmeier
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Marburg, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Elena Nudo
- Global Medical Affairs, Chiesi Farmaceutici, S.p.A, Parma, Italy
| | | | - Derek Skinner
- Observational and Pragmatic Research Institute, Singapore
| | - Rebecca Vella
- Observational and Pragmatic Research Institute, Singapore
| | - Joan B Soriano
- Respiratory Department, Hospital Universitario de La Princesa and Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Maxim Kots
- Global Medical Affairs, Chiesi Farmaceutici, S.p.A, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici, S.p.A, Parma, Italy
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Whittaker HR, Torkpour A, Quint J. Eligibility of patients with chronic obstructive pulmonary disease for inclusion in randomised control trials investigating triple therapy: a study using routinely collected data. Respir Res 2024; 25:43. [PMID: 38238769 PMCID: PMC10797743 DOI: 10.1186/s12931-024-02672-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Randomised control trials (RCTs) with strict eligibility criteria can lead to trial populations not commonly seen in clinical practice. We described the proportion of people with chronic obstructive pulmonary disease (COPD) in England eligible for RCTs investigating treatment with triple therapy. METHODS MEDLINE and Clinicaltrials.gov were searched for RCTs investigating triple therapy and eligibility criteria for each trial were extracted. Using routinely collected primary care data from Clinical Practice Research Datalink Aurum linked with Hospital Episode Statistics, we defined a population of COPD patients registered at a general practice in England, who were ≥ 40 years old, and had a history of smoking. Inclusion date was January 1, 2020. Patients who died earlier or left the general practice were excluded. Eligibility criteria for each RCT was applied to the population of COPD patients and the proportion of patients meeting each trial eligibility criteria were described. RESULTS 26 RCTs investigating triple therapy were identified from the literature. The most common eligibility criteria were post-bronchodilator FEV1% predicted 30-80%, ≥ 2 moderate/≥ 1 severe exacerbations 12-months prior, no moderate exacerbations one-month prior and no severe exacerbations three-months prior, and the use of maintenance therapy or ICS use prior to inclusion. After applying each RCT eligibility criteria to our population of 79,810 COPD patients, a median of 11.2% [interquartile range (IQR) 1.8-17.4] of patients met eligibility criteria. The most discriminatory criteria included the presence exacerbations of COPD and previous COPD related medication use with a median of 67.6% (IQR 8.5-73.4) and 63% (IQR 69.3-38.4) of COPD patients not meeting these criteria, respectively. CONCLUSION Data from these RCTs may not be generalisable to the wider population of people with COPD seen in everyday clinical practice and real-world evidence studies are needed to supplement trials to understand effectiveness in all people with COPD.
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Affiliation(s)
| | - Aria Torkpour
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Jennifer Quint
- School of Public Health, Imperial College London, London, UK
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25
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Beeh KM, Scheithe K, Schmutzler H, Krüger S. Real-World Effectiveness of Fluticasone Furoate/Umeclidinium/Vilanterol Once-Daily Single-Inhaler Triple Therapy for Symptomatic COPD: The ELLITHE Non-Interventional Trial. Int J Chron Obstruct Pulmon Dis 2024; 19:205-216. [PMID: 38249826 PMCID: PMC10800114 DOI: 10.2147/copd.s427770] [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: 09/26/2023] [Accepted: 12/08/2023] [Indexed: 01/23/2024] Open
Abstract
Purpose Real-life effectiveness data on once-daily single-inhaler triple therapy (odSITT) with the inhaled corticosteroid fluticasone furoate (FF), the long-acting muscarinic antagonist umeclidinium (UMEC), and the long-acting β2-agonist vilanterol (VI) in patients with chronic obstructive pulmonary disease (COPD) are important to complement evidence from well-controlled randomized clinical trials. Effectiveness of odSITT was quantified by assessing health status and symptoms in usual care. Patients and Methods ELLITHE was a single-country (Germany), multicenter, open-label, non-interventional effectiveness study between 2020 and 2022, evaluating the effect of treatment initiation with FF/UMEC/VI 100/62.5/25 µg once-daily via the ELLIPTA inhaler on improvements in clinical outcomes versus baseline in COPD patients. The primary endpoint was the change in the total COPD Assessment Test (CAT) score between baseline and month 12. Key secondary endpoints included change in CAT score over time, occurrence of exacerbations until month 12, changes in forced expiratory volume in one second (FEV1), inhaler adherence, and safety. Results Nine hundred and six patients were included (age 66.6 years, 55.6% male, mean FEV1 52.6% of predicted, mean CAT 21.5 units, 1.4 exacerbations/year pre-study). About 63.9% of patients were escalated from dual therapies, and 18% were switched from multiple-inhaler triple therapies. Reductions in CAT score at month 12 were statistically significant and above the threshold of clinical importance (-2.6 units; p < 0.0001). CAT score also improved at interim visits. CAT improvements were more pronounced in patients with high baseline scores and better inhaler adherence. Exacerbations during follow-up were rare (0.2 events/year) compared to pre-study (1.4 events/year). FEV1 was improved by 93 mL (p < 0.0001). No new safety effects were observed. Conclusion In usual care, treatment with odSITT resulted in significant and clinically relevant improvements of CAT score and FEV1 in COPD patients, regardless of the occurrence of exacerbations. These findings challenge the current guideline recommendations for SITT only in patients experiencing exacerbations.
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Affiliation(s)
| | - Karl Scheithe
- Department of Biostatistics, GKM Gesellschaft Für Therapieforschung mbH, Munich, Germany
| | | | - Saskia Krüger
- Medical Department, BERLIN-CHEMIE AG, Berlin, Germany
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26
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Saint-Pierre MD. Severe Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Are There Significant Differences Between Hospitalized and Emergency Department Patients? Int J Chron Obstruct Pulmon Dis 2024; 19:133-138. [PMID: 38249827 PMCID: PMC10799575 DOI: 10.2147/copd.s447477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
Rationale Current guidelines define a severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) as an increase in symptoms requiring hospital admission or emergency department (ED) visit. Little is known about whether or not subjects requiring hospitalization and those needing only ED care have similar patient profiles and if their clinical outcomes appear comparable. Objective The main goals of this study were to compare the demographic and clinical characteristics of patients treated for an AECOPD with an inpatient admission versus an ED visit and to review if hospital resource utilization was different between the 2 groups after discharge. Methods Subjects treated in 2022 at Montfort Hospital for an AECOPD were reviewed. Patient demographic information was collected in addition to spirometry results and blood eosinophil counts on file. Supplemental oxygen use and medication lists were also recorded. Patients with an initial hospital admission were compared to those requiring only ED care with univariate and multivariate analyses. We also assessed if subjects were again treated for an AECOPD up to 6 months post initial discharge, and if so, the type of hospital visits (hospitalization or ED). Measurements and Main Results A total of 135 individuals necessitated hospitalization and 79 received ED care for the treatment of an AECOPD. On univariate analysis, patients requiring an inpatient stay appeared older and were more likely to have spirometry results on file. A greater proportion of hospitalized individuals were on supplemental oxygen and prescribed at least one long-acting inhaled medication. These studied variables remained significant after multivariate logistic regression analysis. Subjects with an initial inpatient admission were also more likely to require hospitalization upon repeat presentation for a severe AECOPD. Conclusion Given the important differences observed in both patient characteristics and hospital resource utilization, this study supports considering an AECOPD requiring inpatient admission versus an ED visit as distinct categories of events.
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Affiliation(s)
- Mathieu D Saint-Pierre
- University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada
- Institut du Savoir Montfort, Ottawa, ON, Canada
- Montfort Hospital, Division of Respirology, Ottawa, ON, Canada
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27
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Jackson D, Jenkins M, de Nigris E, Purkayastha D, Patel M, Ouwens M. Associations between the EQ-5D-5L and exacerbations of chronic obstructive pulmonary disease in the ETHOS trial. Qual Life Res 2024:10.1007/s11136-023-03582-z. [PMID: 38206455 DOI: 10.1007/s11136-023-03582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with deteriorating health and health-related quality of life (HRQoL) among people with COPD during and after events. HRQoL data are key to evaluating treatment cost-effectiveness and informing reimbursement decisions in COPD. EuroQoL 5-dimension 5-level (EQ-5D-5L) utility scores, based on various HRQoL measures, are used in economic evaluations of pharmacotherapy. These analyses estimated associations between EQ-5D-5L utility scores and exacerbations (new and previous) in patients with moderate-to-very severe COPD. METHODS Longitudinal mixed models for repeated measures (MMRM), adjusted for time and treatment, were conducted using data from the ETHOS study (NCT02465567); models regressed EQ-5D-5L on current and past exacerbations that occurred during the study, adjusting for other patient reported outcomes and clinical factors. RESULTS Based on the simplest covariate adjusted model (adjusted for current exacerbations and number of previous exacerbations during the study), a current moderate exacerbation was associated with an EQ-5D-5L disutility of 0.055 (95% confidence interval: 0.048, 0.062) with an additional disutility of 0.035 (0.014, 0.055) if the exacerbation was severe. After resolving, each prior exacerbation was associated with a disutility that persisted for the remainder of the study (moderate exacerbation, 0.014 [0.011, 0.016]; further disutility for severe exacerbation, 0.011 [0.003, 0.018]). CONCLUSION An EQ-5D-5L disutility of 0.090 was associated with a current severe exacerbation in ETHOS. Our findings suggest incorporating the effects of current, recently resolved, and cumulative exacerbations into economic models when estimating benefits and costs of COPD pharmacotherapy, as exacerbations have both acute and persistent effects.
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Sharma M, Joshi S, Banjade P, Ghamande SA, Surani S. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Guidelines Reviewed. Open Respir Med J 2024; 18:e18743064279064. [PMID: 38660684 PMCID: PMC11037508 DOI: 10.2174/0118743064279064231227070344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/10/2023] [Accepted: 12/11/2023] [Indexed: 04/26/2024] Open
Abstract
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report is an essential resource for all clinicians who strive to provide optimal care to patients with chronic obstructive lung disease (COPD). The annual report of GOLD makes few revisions and updates besides including data from the preceding year. At an interval, GOLD comes up with a significant modification in its guidelines, which is generally a major overhaul of the pre-existing guidelines. According to the latest 2023 updates, published in November 2022, there have been significant advancements made in the field of COPD. These include the development of more precise definitions for COPD and its exacerbations, the introduction of a new set of parameters to measure exacerbation severity, and updating the COPD assessment tool. Additionally, revisions have been made to the initial and follow-up treatment guidelines. The report also simplifies the treatment algorithm and sheds light on new findings that suggest the use of pharmacological triple therapy can reduce mortality rates. Furthermore, the report includes discussions on inhaler device selection and adherence to COPD medications. These improvements demonstrate a continued effort to enhance COPD treatment and management. Although there are some areas that could benefit from more detailed guidance and explanation, such as the proper utilization of blood eosinophil counts for treatment decisions, and the establishment of treatment protocols post-hospitalization, the latest modifications to the GOLD recommendations will undoubtedly aid healthcare providers in addressing any gaps in patient care. We aim to highlight key changes in the GOLD 2023 report and present a viewpoint about their potential implications in a real-world clinical scenario.
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Affiliation(s)
- Munish Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Medical Center, Temple, Texas
| | - Sushil Joshi
- Department of Medicine, Mantra Hospital and Research Center, Kanchanpur, Nepal. Nepalese Army Institute of Health Science, Kathmandu, Nepal
| | - Prakash Banjade
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Medical Center, Baylor College of Medicine, Temple, Texas
| | - Shekhar A Ghamande
- Adjunct Clinical Professor of Medicine, Texas A and M University, Texas, United States
| | - Salim Surani
- Adjunct Clinical Professor of Medicine, Texas A and M University, Texas, United States
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Riesco Miranda JA, Calle Rubio M, Díaz Pérez D, López-Campos JL, Trigueros Carrero JA, Celli B. Efficacy and Safety of Single-inhaler Triple Therapy Containing Dual Bronchodilator With Corticosteroids Compared to Monotherapy, Dual Therapy, or Open Triple Therapy in Moderate/Severe COPD: A Systematic Literature Review. Arch Bronconeumol 2024; 60:55-58. [PMID: 37985278 DOI: 10.1016/j.arbres.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/17/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023]
Affiliation(s)
| | - Myriam Calle Rubio
- Servicio de Neumología, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - David Díaz Pérez
- Servicio de Neumología y Cirugía Torácica, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Jose Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | | | - Bartolomé Celli
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard University Medical School, Boston, MA, USA
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Lea S, Higham A, Beech A, Singh D. How inhaled corticosteroids target inflammation in COPD. Eur Respir Rev 2023; 32:230084. [PMID: 37852657 PMCID: PMC10582931 DOI: 10.1183/16000617.0084-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/05/2023] [Indexed: 10/20/2023] Open
Abstract
Inhaled corticosteroids (ICS) are the most commonly used anti-inflammatory drugs for the treatment of COPD. COPD has been previously described as a "corticosteroid-resistant" condition, but current clinical trial evidence shows that selected COPD patients, namely those with increased exacerbation risk plus higher blood eosinophil count (BEC), can benefit from ICS treatment. This review describes the components of inflammation modulated by ICS in COPD and the reasons for the variation in response to ICS between individuals. There are corticosteroid-insensitive inflammatory pathways in COPD, such as bacteria-induced macrophage interleukin-8 production and resultant neutrophil recruitment, but also corticosteroid-sensitive pathways including the reduction of type 2 markers and mast cell numbers. The review also describes the mechanisms whereby ICS can skew the lung microbiome, with reduced diversity and increased relative abundance, towards an excess of proteobacteria. BEC is a biomarker used to enable the selective use of ICS in COPD, but the clinical outcome in an individual is decided by a complex interacting network involving the microbiome and airway inflammation.
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Affiliation(s)
- Simon Lea
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Andrew Higham
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Augusta Beech
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Dave Singh
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
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Romiti GF, Corica B, Mei DA, Frost F, Bisson A, Boriani G, Bucci T, Olshansky B, Chao TF, Huisman MV, Proietti M, Lip GYH. Impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: an analysis from the GLORIA-AF registry. Europace 2023; 26:euae021. [PMID: 38266129 PMCID: PMC10825625 DOI: 10.1093/europace/euae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024] Open
Abstract
AIMS Chronic obstructive pulmonary disease (COPD) may influence management and prognosis of atrial fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes. METHODS AND RESULTS From the prospective, global GLORIA-AF registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). A total of 36 263 patients (mean age 70.1 ± 10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. The prevalence of COPD was lower in Asia and higher in North America. Age, female sex, smoking, body mass index, and cardiovascular comorbidities were associated with the presence of COPD. Chronic obstructive pulmonary disease was associated with higher use of oral anticoagulant (OAC) [adjusted odds ratio (aOR) and 95% confidence interval (CI): 1.29 (1.13-1.47)] and higher OAC discontinuation [adjusted hazard ratio (aHR) and 95% CI: 1.12 (1.01-1.25)]. Chronic obstructive pulmonary disease was associated with less use of beta-blocker [aOR (95% CI): 0.79 (0.72-0.87)], amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had a higher hazard of primary composite outcome [aHR (95% CI): 1.78 (1.58-2.00)]; no interaction was observed regarding beta-blocker use. Chronic obstructive pulmonary disease was also associated with all-cause death [aHR (95% CI): 2.01 (1.77-2.28)], MACEs [aHR (95% CI): 1.41 (1.18-1.68)], and major bleeding [aHR (95% CI): 1.48 (1.16-1.88)]. CONCLUSION In AF patients, COPD was associated with differences in OAC treatment and use of other drugs; Patients with AF and COPD had worse outcomes, including higher mortality, MACE, and major bleeding.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Davide Antonio Mei
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Frederick Frost
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Arnaud Bisson
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General Surgery and Surgical Specialties ‘Paride Stefanini’, Sapienza – University of Rome, Rome, Italy
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, USA
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Weir DL, Bai YQ, Thavorn K, Guilcher S, Kanji S, Mulpuru S, Wodchis W. Non-Adherence to COPD Medications and its Association with Adverse Events: A Longitudinal Population Based Cohort Study of Older Adults. Ann Epidemiol 2023:S1047-2797(23)00228-4. [PMID: 38141744 DOI: 10.1016/j.annepidem.2023.12.003] [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: 07/14/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE To determine the association between non-adherence to long term chronic obstructive pulmonary disease (COPD) medications and COPD related emergency department (ED) visits and hospitalizations in patients with incident COPD, utilizing time varying measures of adherence as well as accounting for time-varying confounding impacted by prior adherence. STUDY DESIGN AND SETTING We conducted a population-based retrospective cohort study between 2007-2017 among individuals aged 66 years and older with incident COPD using multiple linked administrative health databases from the province of Ontario, Canada. Adherence to COPD medications was measured using time varying proportion of days covered based on insurance claims for medications dispensed at community pharmacies. The parametric g-formula was used to assess the association between time-varying adherence (in the last 90-days) to COPD medications and risk of COPD related hospitalizations and ED visits while accounting for time varying confounding by COPD severity. RESULTS Overall, 60,251 individuals with incident COPD were included; mean age was 76 (SD 7) and 59% were male. Mean adherence over the entire follow-up was 23% (SD 0.3). There were 7,248 (12%) COPD related ED visits (2.8 events per 100 person years [PY]) and 9,188 (15%) COPD related hospitalizations (3.5 events per 100 PY). Compared to those with 0% 90-day adherence, those with adherence between 1-33% had a 19% decreased risk of COPD related ED visits (adjusted risk ratio[aRR]:0.81, 95% confidence interval [CI]:0.78-0.83), those with adherence between 34%-67% had a 18% decreased risk (aRR: 0.82, 95% CI: 0.77-0.85) while those with 68%-100% 90-day adherence had a 63% increased risk of COPD related ED visits (aRR: 1.63, 95% CI: 1.47-1.78). Nearly identical results were obtained for COPD specific hospitalizations. CONCLUSION After accounting for time varying confounding by COPD severity, the highest time varying 90-days adherence was associated with an increased risk of both COPD related ED visits and hospitalizations compared to the lowest adherence categories. Differences in COPD severity between adherence categories, perception of need for medication management in the higher adherence categories, and potential residual confounding makes it difficult to disentangle the independent effects of adherence from the severity of the condition itself.
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Affiliation(s)
- Daniala L Weir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Utrecht Institute of Pharmaceutical Sciences, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.
| | - Yu Qing Bai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sara Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario Canada
| | - Walter Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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Bolger GB. Therapeutic Targets and Precision Medicine in COPD: Inflammation, Ion Channels, Both, or Neither? Int J Mol Sci 2023; 24:17363. [PMID: 38139192 PMCID: PMC10744217 DOI: 10.3390/ijms242417363] [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] [Received: 11/13/2023] [Revised: 12/04/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
The development of a wider range of therapeutic options is a key objective in drug discovery for chronic obstructive pulmonary disease (COPD). Fundamental advances in lung biology have the potential to greatly expand the number of therapeutic targets in COPD. The recently reported successful Phase 3 clinical trial of the first biologic agent for COPD, the monoclonal antibody dupilumab, adds additional support to the importance of targeting inflammatory pathways in COPD. However, numerous other cellular mechanisms are important targets in COPD therapeutics, including airway remodeling, the CFTR ion channel, and mucociliary function. Some of these emerging targets can be exploited by the expanded use of existing COPD drugs, such as roflumilast, while targeting others will require the development of novel molecular entities. The identification of additional therapeutic targets and agents has the potential to greatly expand the value of using clinical and biomarker data to classify COPD into specific subsets, each of which can be predictive of an enhanced response to specific subset(s) of targeted therapies. The author reviews established and emerging drug targets in COPD and uses this as a framework to define a novel classification of COPD based on therapeutic targets. This novel classification has the potential to enhance precision medicine in COPD patient care and to accelerate clinical trials and pre-clinical drug discovery efforts.
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Affiliation(s)
- Graeme B Bolger
- BZI Pharma LLC, 1500 1st Ave N., Unit 36, Birmingham, AL 35203-1872, USA
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Morena D, Izquierdo JL, Rodríguez J, Cuesta J, Benavent M, Perralejo A, Rodríguez JM. The Clinical Profile of Patients with COPD Is Conditioned by Age. J Clin Med 2023; 12:7595. [PMID: 38137664 PMCID: PMC10743861 DOI: 10.3390/jcm12247595] [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: 10/28/2023] [Revised: 11/21/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
In recent years, many studies have analyzed the importance of integrating time, or aging, into the equation that relates genetics and the environment to the development and origin of COPD. Under conditions of daily clinical practice, our study attempts to identify the differences in the clinical profile of patients with COPD according to age and the impact on the global burden of the disease. This study is non-interventional and observational, using artificial intelligence and data captured from electronic medical records. The study population included patients who were diagnosed with COPD between 2011 and 2021. A total of 73,901 patients had a diagnosis of COPD. The mean age was 73 years (95% CI: 72.9-73.1), and 56,763 were men (76.8%). We observed a specific prevalence of obesity, heart failure, depression, and hiatal hernia in women (p < 0.001), and ischemic heart disease and obstructive sleep apnea (OSA) in men (p < 0.001). In the analysis by age ranges, a progressive increase in cardiovascular risk factors was observed with age. In conclusion, in a real-life setting, COPD is a disease that primarily affects older subjects and frequently presents with comorbidities that are decisive in the evolutionary course of the disease.
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Affiliation(s)
- Diego Morena
- Pulmonology Department, Respiratory Medicine, Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain;
- Doctoral Program in Health Sciences, University of Alcalá, 28871 Alcalá de Henares, Spain
| | - José Luis Izquierdo
- Pulmonology Department, Respiratory Medicine, Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain;
- Department of Medicine and Medical Specialties, University of Alcalá, 28871 Alcalá de Henares, Spain; (J.C.); (J.M.R.)
| | - Juan Rodríguez
- Geriatric Medicine, Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain;
| | - Jesús Cuesta
- Department of Medicine and Medical Specialties, University of Alcalá, 28871 Alcalá de Henares, Spain; (J.C.); (J.M.R.)
| | | | | | - José Miguel Rodríguez
- Department of Medicine and Medical Specialties, University of Alcalá, 28871 Alcalá de Henares, Spain; (J.C.); (J.M.R.)
- Respiratory Medicine, Hospital Universitario Príncipe de Asturias, 28805 Alcalá de Henares, Spain
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van Geffen WH, Tan DJ, Walters JA, Walters EH. Inhaled corticosteroids with combination inhaled long-acting beta2-agonists and long-acting muscarinic antagonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2023; 12:CD011600. [PMID: 38054551 PMCID: PMC10698842 DOI: 10.1002/14651858.cd011600.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Management of chronic obstructive pulmonary disease (COPD) commonly involves a combination of long-acting bronchodilators including beta2-agonists (LABA) and muscarinic antagonists (LAMA). LABA and LAMA bronchodilators are now available in single-combination inhalers. In individuals with persistent symptoms or frequent exacerbations, inhaled corticosteroids (ICS) are also used with combination LABA and LAMA inhalers. However, the benefits and risks of adding ICS to combination LABA/LAMA inhalers as a triple therapy remain unclear. OBJECTIVES To assess the effects of adding an ICS to combination LABA/LAMA inhalers for the treatment of stable COPD. SEARCH METHODS We searched the Cochrane Airways Group Register of Trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase up to 30 November 2022. We also searched ClinicalTrials.gov and the WHO ICTRP up to 30 November 2022. SELECTION CRITERIA We included parallel-group randomised controlled trials of three weeks' duration or longer that compared the treatment of stable COPD with ICS in addition to combination LABA/LAMA inhalers against combination LABA/LAMA inhalers alone. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. The primary outcomes were acute exacerbations of COPD, respiratory health-related quality of life, pneumonia and other serious adverse events. The secondary outcomes were symptom scores, lung function, physical capacity, and mortality. We used GRADE to assess certainty of evidence for studies that contributed data to our prespecified outcomes. MAIN RESULTS Four studies with a total of 15,412 participants met the inclusion criteria. The mean age of study participants ranged from 64.4 to 65.3 years; the proportion of female participants ranged from 28% to 40%. Most participants had symptomatic COPD (COPD Assessment Test Score ≥ 10) with severe to very severe airflow limitation (forced expiratory volume in one second (FEV1) < 50% predicted) and one or more moderate-to-severe COPD exacerbations in the last 12 months. Trial medications differed amongst studies. The duration of follow-up was 52 weeks in three studies and 24 weeks in one study. We assessed the risk of selection, performance, and detection bias to be low in the included studies; one study was at high risk of attrition bias, and one study was at high risk of reporting bias. Triple therapy may reduce rates of moderate-to-severe COPD exacerbations compared to combination LABA/LAMA inhalers (rate ratio (RR) 0.74, 95% confidence interval (CI) 0.67 to 0.81; n = 15,397; low-certainty evidence). Subgroup analysis stratifying by blood eosinophil counts showed there may be a greater reduction in rate of moderate-to-severe COPD exacerbations with triple therapy in participants with high-eosinophils (RR 0.67, 95% CI 0.60 to 0.75) compared to low-eosinophils (RR 0.87, 95% CI 0.81 to 0.93) (test for subgroup differences: P < 0.01) (high/low cut-offs: 150 eosinophils/µL in three studies; 200 eosinophils/µL in one study). However, moderate-to-substantial heterogeneity was observed in both high- and low-eosinophil subgroups. These subgroup analyses are observational by nature and thus results should be interpreted with caution. Triple therapy may be associated with reduced rates of severe COPD exacerbations (RR 0.75, 95% CI 0.67 to 0.84; n = 14,131; low-certainty evidence). Triple therapy improved health-related quality of life assessed using the St George's Respiratory Questionnaire (SGRQ) by the minimal clinically important difference (MCID) threshold (4-point decrease) (35.3% versus 42.4%, odds ratio (OR) 1.35, 95% CI 1.26 to 1.45; n = 14,070; high-certainty evidence). Triple therapy may result in fewer symptoms measured using the Transition Dyspnoea Index (TDI) (OR 1.33, 95% CI 1.13 to 1.57; n = 3044; moderate-certainty evidence) and improved lung function as measured by change in trough FEV1 (mean difference 38.68 mL, 95% CI 22.58 to 54.77; n = 11,352; low-certainty evidence). However, these benefits fell below MCID thresholds for TDI (1-unit decrease) and trough FEV1 (100 mL), respectively. Triple therapy is probably associated with a higher risk of pneumonia as a serious adverse event compared to combination LABA/LAMA inhalers (3.3% versus 1.9%, OR 1.74, 95% CI 1.39 to 2.18; n = 15,412; moderate-certainty evidence). In contrast, all-cause serious adverse events may be similar between groups (19.7% versus 19.7%, OR 0.95, 95% CI 0.87 to 1.03; n = 15,412; low-certainty evidence). All-cause mortality may be lower with triple therapy (1.4% versus 2.0%, OR 0.70, 95% CI 0.54 to 0.90; n = 15,397; low-certainty evidence). AUTHORS' CONCLUSIONS The available evidence suggests that triple therapy may reduce rates of COPD exacerbations (low-certainty evidence) and results in an improvement in health-related quality of life (high-certainty evidence) compared to combination LABA/LAMA inhalers, but probably confers an increased pneumonia risk as a serious adverse event (moderate-certainty evidence). Triple therapy probably improves respiratory symptoms and may improve lung function (moderate- and low-certainty evidence, respectively); however, these benefits do not appear to be clinically significant. Triple therapy may reduce the risk of all-cause mortality compared to combination LABA/LAMA inhalers (low-certainty evidence). The certainty of the evidence was downgraded most frequently for inconsistency or indirectness. Across the four included studies, there were important differences in inclusion criteria, trial medications, and duration of follow-up. Investigation of heterogeneity was limited due to the small number of included studies. We found limited data on the effects of triple therapy compared to combination LABA/LAMA inhalers in patients with mild-moderate COPD and those without a recent exacerbation history.
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Affiliation(s)
- Wouter H van Geffen
- Department of Pulmonary Diseases, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Daniel J Tan
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | | | - E Haydn Walters
- NHMRC Centre of Research Excellence for Chronic Respiratory Disease, School of Medicine, University of Tasmania, Hobart, Australia
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Celli B, Vestbo J. Reply: Simplifying pharmacotherapy for patients with COPD: a viewpoint. Eur Respir J 2023; 62:2301600. [PMID: 38097203 DOI: 10.1183/13993003.01600-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Bartolome Celli
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and the North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
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Suissa S. Simplifying pharmacotherapy for patients with COPD: a viewpoint. Eur Respir J 2023; 62:2301510. [PMID: 38097204 DOI: 10.1183/13993003.01510-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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Calzetta L, Rogliani P. Bayesian or frequentist: there is no question when comparing single-inhaler triple therapies via network meta-analysis. Focus on fluticasone furoate/umeclidinium/vilanterol fixed-dose combination in chronic obstructive pulmonary disease. Expert Rev Respir Med 2023; 17:1273-1283. [PMID: 38318884 DOI: 10.1080/17476348.2024.2316167] [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] [Received: 08/02/2023] [Accepted: 02/05/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVES Single-inhaler triple therapies (SITTs) have never been directly compared in randomized controlled trials (RCTs) in chronic obstructive pulmonary disease (COPD). Cochrane recommends the Bayesian approach for indirect comparisons but a frequentist network meta-analysis (NMA) reported superiority of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) over other SITT. We assessed the most appropriate inference method for NMA characterized by between-study heterogeneity on SITT in COPD. METHODS Bayesian and frequentist NMA were performed on RCTs investigating the effect of SITT on exacerbations and trough forced expiratory volume in the 1st second (FEV1) in COPD. RESULTS The included RCTs (ETHOS, FULFIL, IMPACT, KRONOS 200812) reported significant between-study heterogeneity (I2 > 99%, p < 0.001). The Bayesian random-effect NMA provided unbiased evidence that FF/UMEC/VI was not superior to other SITT on exacerbations and trough FEV1. The frequentist fixed-effect NMA indicated that FF/UMEC/VI was significantly (p < 0.05) more effective than other SITT, although results were affected by dispersion, asymmetry, and significant risk of bias. Frequentist random-effect NMA provided effect estimates rather similar but not equal to those of Bayesian approach. CONCLUSION Indirect comparison should be performed via Bayesian approach instead of frequentist inference with a fixed-effect model. Claiming the superiority of a specific medication over other therapies should be confirmed by findings originating from well-designed RCTs.
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Affiliation(s)
- Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Tryfon S, Papadopoulou E, Bertoli M, Exarchos K, Ginis A, Kostikas K. Lung function and exacerbations in patients with COPD escalated to triple therapy: The RETRIEVE real-world study. Respirology 2023; 28:1166-1169. [PMID: 37879756 DOI: 10.1111/resp.14612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Stavros Tryfon
- Pulmonology Department, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
| | - Efthymia Papadopoulou
- Pulmonology Department, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
| | - Maria Bertoli
- Medical Department, ELPEN Pharmaceutical Co. Inc., Pikermi, Greece
| | - Konstantinos Exarchos
- Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Alexandros Ginis
- Medical Department, ELPEN Pharmaceutical Co. Inc., Pikermi, Greece
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
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Tse G, Emmanuel B, Ariti C, Bafadhel M, Papi A, Carter V, Zhou J, Skinner D, Xu X, Müllerová H, Price D. A Long-Term Study of Adverse Outcomes Associated With Oral Corticosteroid Use in COPD. Int J Chron Obstruct Pulmon Dis 2023; 18:2565-2580. [PMID: 38022830 PMCID: PMC10657769 DOI: 10.2147/copd.s433326] [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: 08/01/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Background Oral corticosteroids (OCS) are often prescribed for chronic obstructive pulmonary disease (COPD) exacerbations. Methods This observational, individually matched historical cohort study used electronic medical records (1987-2019) from the UK Clinical Practice Research Datalink linked to English Hospital Episode Statistics (HES) to evaluate adverse outcomes in patients with COPD who used OCS (OCS cohort) and those not exposed to OCS (non-OCS cohort). Risk of 17 adverse outcomes was estimated using proportional hazard regression. Results Of 323,722 patients, 106,775 (33.0%) had COPD-related OCS prescriptions. Of the 106,775 patients in the overall cohort, 58,955 had HES linkage and were eligible for inclusion in the OCS cohort. The individual matching process identified 53,299 pairs of patients to form the OCS and non-OCS cohorts. Median follow-up post-index was 6.9 years (OCS cohort) and 5.4 years (non-OCS cohort). Adjusted risk of multiple adverse outcomes was higher for the OCS cohort versus the non-OCS cohort, including osteoporosis with/without fractures (adjusted hazard ratio [aHR] 1.80; 95% confidence interval [CI] 1.70-1.92), type 2 diabetes mellitus (aHR 1.44; 95% CI 1.37-1.51), cardiovascular/cerebrovascular disease (aHR 1.26; 95% CI 1.21-1.30), and all-cause mortality (aHR 1.04; 95% CI 1.02-1.07). In the OCS cohort, risk of most adverse outcomes increased with increasing categorized cumulative OCS dose. For example, risk of cardiovascular/cerebrovascular disease was 34% higher in the 1.0-<2.5 g group versus the <0.5 g group (HR 1.34; 95% CI 1.26-1.42). Conclusion Any OCS use was associated with higher risk of adverse outcomes in patients with COPD, with risk generally increasing with greater cumulative OCS dose.
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Affiliation(s)
- Gary Tse
- Observational and Pragmatic Research Institute, Singapore, Singapore
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, People’s Republic of China
| | | | - Cono Ariti
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Mona Bafadhel
- Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Alberto Papi
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Jiandong Zhou
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Derek Skinner
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Xiao Xu
- AstraZeneca, Gaithersburg, MD, USA
| | | | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Hu HS, Wang Z, Jian LY, Zhao LM, Liu XD. Optimizing inhaled corticosteroid use in patients with chronic obstructive pulmonary disease: assessing blood eosinophils, neutrophil-to-lymphocyte ratio, and mortality outcomes in US adults. Front Immunol 2023; 14:1230766. [PMID: 38035096 PMCID: PMC10684949 DOI: 10.3389/fimmu.2023.1230766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Objective Accurate biomarkers for evaluating mortality rates in patients with chronic obstructive pulmonary disease (COPD) remain scarce. This study aimed to explore the relationships between mortality rates in patients with COPD and blood eosinophil counts, neutrophil counts, and lymphocyte counts, along with the neutrophil-to-lymphocyte ratio (NLR). Additionally, we sought to identify the optimal response values for these biomarkers when utilizing inhaled corticosteroids (ICS). Methods Utilizing a nationally representative, multistage cross-sectional design and mortality correlation study, we analyzed data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 involving US adults aged 40 years or older with COPD. The primary endpoint was all-cause mortality, with Kaplan-Meier survival curves and restricted cubic splines applied to illustrate the relationship between leukocyte-based inflammatory markers and mortality. The analysis was conducted in 2023. Results Our analysis included 1,715 COPD participants, representing 6,976,232 non-institutionalized US residents [weighted mean age (SE), 62.09 (0.28) years; range, 40-85 years]. Among the participants, men constituted 50.8% of the population, and the weighted mean follow-up duration was 84.9 months. In the ICS use group, the weighted proportion of participants over 70 years old was significantly higher compared with the non-ICS use group (31.39% vs 25.52%, p < 0.0001). The adjusted hazard ratios for all-cause mortality related to neutrophil counts, lymphocyte counts, and NLR were 1.10 [95% confidence interval (CI), 1.04-1.16, p < 0.001], 0.83 (95% CI, 0.71-0.98; p = 0.03), and 1.10 (95% CI, 1.05-1.15; p < 0.0001), respectively. Optimal ICS response was linked with higher levels of eosinophil count (≥240 cells/μL), neutrophil count (≥3,800 cells/μL), NLR (≥4.79), and lower levels of lymphocyte count (<2,400 cells/μL). Conclusion Adjusted baseline neutrophil, lymphocyte counts, and NLR serve as independent risk factors for all-cause mortality in patients with COPD. Further, ICS application appears to mitigate mortality risk, particularly when NLR levels reach 4.79 or higher, underlining the importance of ICS in COPD management.
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Affiliation(s)
- Han-Shuo Hu
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
- Department of The Second Clinical Pharmacy, School of Pharmacy, China Medical University, Shenyang, China
| | - Zhuo Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
- Department of The Second Clinical Pharmacy, School of Pharmacy, China Medical University, Shenyang, China
| | - Ling-Yan Jian
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
- Department of The Second Clinical Pharmacy, School of Pharmacy, China Medical University, Shenyang, China
| | - Li-Mei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
- Department of The Second Clinical Pharmacy, School of Pharmacy, China Medical University, Shenyang, China
| | - Xiao-Dong Liu
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
- Department of The Second Clinical Pharmacy, School of Pharmacy, China Medical University, Shenyang, China
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Echevarria C, Steer J, Prasad A, Quint JK, Bourke SC. Admission blood eosinophil count, inpatient death and death at 1 year in exacerbating patients with COPD. Thorax 2023; 78:1090-1096. [PMID: 37487711 DOI: 10.1136/thorax-2022-219463] [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] [Received: 07/27/2022] [Accepted: 06/16/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Blood eosinophil counts have been studied in patients with stable chronic obstructive pulmonary disease (COPD) and are a useful biomarker to guide inhaled corticosteroid use. Less is known about eosinophil counts during severe exacerbation. METHODS In this retrospective study, 2645 patients admitted consecutively with COPD exacerbation across six UK hospitals were included in the study, and the clinical diagnosis was confirmed by a respiratory specialist. The relationship between admission eosinophil count, inpatient death and 1-year death was assessed. In a backward elimination, Poisson regression analysis using the log-link function with robust estimates, patients' markers of acute illness and stable-state characteristics were assessed in terms of their association with eosinopenia. RESULTS 1369 of 2645 (52%) patients had eosinopenia at admission. Those with eosinopenia had a 2.5-fold increased risk of inpatient death compared with those without eosinopenia (12.1% vs 4.9%, RR=2.50, 95% CI 1.88 to 3.31, p<0.001). The same mortality risk with eosinopenia was seen among the subgroup with pneumonic exacerbation (n=788, 21.3% vs 8.5%, RR=2.5, 95% CI 1.67 to 2.24, p<0.001). In a regression analysis, eosinopenia was significantly associated with: older age and male sex; a higher pulse rate, temperature, neutrophil count, urea and C reactive protein level; a higher proportion of patients with chest X-ray consolidation and a reduced Glasgow Coma Score; and lower systolic and diastolic blood pressure measurements and lower oxygen saturation, albumin, platelet and previous admission counts. DISCUSSION During severe COPD exacerbation, eosinopenia is common and associated with inpatient death and several markers of acute illness. Clinicians should be cautious about using eosinophil results obtained during severe exacerbation to guide treatment decisions regarding inhaled corticosteroid use.
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Affiliation(s)
- Carlos Echevarria
- Respiratory department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - John Steer
- Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
- Respiratory department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Arun Prasad
- Respiratory department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Jennifer K Quint
- Department of Respiratory Epidemiology Occupational Medicine and Public Health, Imperial College London, London, UK
| | - Stephen C Bourke
- Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
- Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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Brunton SA, Hogarth DK. Overuse of long-acting β 2-agonist/inhaled corticosteroids in patients with chronic obstructive pulmonary disease: time to rethink prescribing patterns. Postgrad Med 2023; 135:784-802. [PMID: 38032494 DOI: 10.1080/00325481.2023.2284650] [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] [Received: 09/18/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality globally. In the major revision of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report, the scientific committee concluded that the use of long-acting β2-agonist/inhaled corticosteroids (LABA/ICS) is not encouraged in patients with COPD. However, current prescribing patterns reveal significant use of LABA/ICS. In this paper, the evidence behind the current practice and the latest treatment recommendations is reviewed. We compare the efficacy and safety of combination therapy with long-acting muscarinic antagonist (LAMA) and LABA vs LABA/ICS and note that LAMA/LABA combinations have reduced the annual rate of moderate/severe exacerbations, delayed the time to first exacerbation, and increased post-dose FEV1 vs ICS-based regimens. The GOLD 2023 report recommends treatment with LABA and LAMA combination (preferably as a single inhaler) in patients with persistent dyspnea, with initiation of ICS in patients based on the symptoms (dyspnea and exercise intolerance as indicated by modified Medical Research Council [mMRC] score ≥ 2 and COPD Assessment Test [CAT™] > 20), blood eosinophil count (≥ 300 cells/µL), and exacerbation history (history of hospitalizations for exacerbations of COPD and ≥ 2 moderate exacerbations per year despite appropriate long-acting bronchodilator maintenance therapy). We describe practical recommendations for primary care physicians to optimize therapy for their patients and prevent overuse of ICS-based regimens. We advocate adherence to current recommendations and a greater focus on effective treatments to successfully control symptoms, minimize exacerbation risk, preserve lung function, maximize patient outcomes, and reduce the burden of drug-related adverse events.
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Affiliation(s)
| | - D Kyle Hogarth
- Pulmonary and Critical Care Medicine, The University of Chicago Medicine, Chicago, IL, USA
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Brusselle G, Himpe U, Fievez P, Leys M, Perez Bogerd S, Peché R, Vanderhelst E, Lins M, Capiau P. Evolving to a single inhaler extrafine LABA/LAMA/ICS - Inhalation technique and adherence at the heart of COPD patient care (TRIVOLVE). Respir Med 2023; 218:107368. [PMID: 37562659 DOI: 10.1016/j.rmed.2023.107368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/05/2023] [Accepted: 07/21/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Incorrect inhaler use and poor treatment adherence have a negative impact on COPD outcomes. This multi-centre, single arm, non-interventional, phase IV study investigated whether inhalation technique, treatment adherence and patient outcomes change in patients who evolve from dual therapy or multiple inhaler triple therapy to single inhaler extrafine triple therapy (beclomethasone dipropionate (BDP, 87 μg), formoterol fumarate (FF, 5 μg) and glycopyrronium (G, 9 μg)) in combination with inhalation technique training. METHODS A total of 126 COPD patients were included in the per protocol set. Inhalation technique and treatment adherence were assessed at baseline and at two visits at approximately 3 and 6 months of treatment with extrafine BDP/FF/G. In addition, lung function, symptom score, patient satisfaction and exacerbations (exploratory) were followed up. RESULTS Before switching to single inhaler extrafine BDP/FF/G (baseline), any device errors and critical errors were detected for 28.8% and 9.6% of patients, respectively. After switching to BDP/FF/G, the percentage of patients with any device errors decreased to 14.0% (visit 2) and 16.3% (visit 3), without critical errors at the two follow-up visits. Treatment adherence increased from 67.5% at baseline to 75.8% (visit 2) and 80% (visit 3). In addition, lung function, symptom and patient satisfaction scores improved, whilst exacerbation rates substantially decreased. CONCLUSIONS This observational study demonstrates that in eligible COPD patients in a real-life setting, the switch from dual therapy or multiple inhaler triple therapy to single inhaler extrafine BDP/FF/G in combination with inhalation technique training is associated with improved inhalation technique and adherence.
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Affiliation(s)
- G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.
| | - U Himpe
- Department of Pneumology, AZ Delta, Roeselare, Belgium
| | - P Fievez
- Department of Pneumology, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - M Leys
- Department of Pneumology, AZ Groeninge, Kortrijk, Belgium
| | - S Perez Bogerd
- Department of Pneumology, Hôpital Erasme, Anderlecht, Belgium
| | - R Peché
- Department of Pneumology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - E Vanderhelst
- Department of Pneumology, UZ Brussel, Jette, Belgium
| | - M Lins
- Department of Pneumology, AZ Sint-Maarten, Mechelen, Belgium
| | - P Capiau
- Medical Affairs Department Chiesi SA/NV, Diegem, Belgium
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Calle Rubio M, Miravitlles M, López-Campos JL, Alcázar Navarrete B, Soler Cataluña JJ, Fuentes Ferrer ME, Rodríguez Hermosa JL. Inhaled Maintenance Therapy in the Follow-Up of COPD in Outpatient Respiratory Clinics. Factors Related to Inhaled Corticosteroid Use. EPOCONSUL 2021 Audit. Arch Bronconeumol 2023; 59:725-735. [PMID: 37563018 DOI: 10.1016/j.arbres.2023.07.015] [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] [Received: 06/01/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE The aim of this analysis was to describe the patterns of inhaled maintenance therapy according to risk level and to explore the determinants associated with the decision to prescribe inhaled corticosteroids (ICS) in addition to bronchodilator therapy according to risk level as strategy in the follow-up of COPD in daily clinical practice. METHODS EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to patients with a diagnosis of chronic obstructive pulmonary disease (COPD) in respiratory clinics in Spain with prospective recruitment between April 15, 2021 and January 31, 2022. RESULTS 4225 patients from 45 hospitals in Spain were audited. Risk levels were analyzed in 2678 patients. 74.5% of patients were classified as high risk and 25.5% as low risk according to GesEPOC criteria. Factors associated with the prescription of ICS in low-risk COPD were symptoms suggestive of asthma [OR: 6.70 (3.14-14.29), p<0.001], peripheral blood eosinophilia>300mm3 [OR: 2.16 (1.10-4.24), p=0.025], and having a predicted FEV1%<80% [OR: 2.17 (1.15-4.08), p=0.016]. In high-risk COPD, factors associated with triple therapy versus dual bronchodilator therapy were a mMRC dyspnea score of ≥2 [OR: 1.97 (1.41-2.75), p<0.001], symptoms suggestive of asthma [OR: 6.70 (3.14-14.29), p<0.001], and a predicted FEV1%<50% [OR: 3.09 (1.29-7.41), p<0.011]. CONCLUSIONS Inhaled therapy in the follow-up of COPD does not always conform to the current guidelines. Few changes in inhaled therapy are made at follow-up visits. The use of ICS is common in COPD patients who meet low-risk criteria in their follow-up and triple therapy in high-risk COPD patients is used as an escalation strategy in patients with high clinical impact. However, a history of exacerbations and eosinophil count in peripheral blood were not factors predicting triple therapy.
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Affiliation(s)
- Myriam Calle Rubio
- Pulmonology Department, Hospital Clínico San Carlos, Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Marc Miravitlles
- Pulmonology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - José Luis López-Campos
- Respiratory Disease Medical-Surgical Unit, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Manuel E Fuentes Ferrer
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Juan Luis Rodríguez Hermosa
- Pulmonology Department, Hospital Clínico San Carlos, Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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Zysman M, Mahay G, Guibert N, Barnig C, Leroy S, Guilleminault L. Impact of pharmacological and non-pharmacological interventions on mortality in chronic obstructive pulmonary disease (COPD) patients. Respir Med Res 2023; 84:101035. [PMID: 37651981 DOI: 10.1016/j.resmer.2023.101035] [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] [Received: 03/02/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE This review aimed to summarise evidence about the impact of pharmacological and non-pharmacological interventions on survival in COPD patients. METHODS We performed a narrative literature review on the effect of pharmacological and non-pharmacological interventions on survival in COPD patients. RESULTS Inhaled therapies are central to reduce symptoms in COPD. In particular, inhaled steroids seem to have the greatest effect on mortality. Despite the anti-inflammatory effects attributed to statins, their benefit in COPD has been shown only in cases of combined cardiovascular diseases. The use of beta-blockers in COPD has not been associated with increased COPD-related mortality and a beneficial effect on all-cause mortality has even been shown in COPD patients with cardiovascular diseases. Influenza and pneumococcal vaccination reduced the occurrence of exacerbations and mortality due to COPD. In addition, long-term oxygen therapy (LTOT) (≥15h/day) in COPD patients with severe hypoxemia had a positive effect on survival. Regarding non-pharmacological interventions, it has been demonstrated that smoking cessation, treatment compliance and nutritional supplementation for underweight patients also have a positive effect on survival. Non-invasive ventilation results were dependent on patient PaCO2 levels. In patients with advanced COPD, further prospective studies are needed to know the effect of bronchoscopic lung volume reduction and lung transplant on COPD survival. Regarding lung transplant, a survival benefit in patients with a pre-transplant BODE score of ≥7 has been shown in retrospective studies. CONCLUSION Most of the studies did not evaluate survival as the main criteria and further long-term studies on the global management of COPD are required.
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Affiliation(s)
- Maeva Zysman
- Service de Pneumologie, CHU Haut-Lévèque, Bordeaux, France; Univ. Bordeaux, Centre de Recherche cardio-thoracique, INSERM U1045, CIC 1401, Pessac, France
| | - Guillaume Mahay
- Service de Pneumologie, Oncologie thoracique et soins intensifs respiratoires, CHU Rouen, Rouen, France
| | - Nicolas Guibert
- Pôle des voies respiratoires, CHU de Toulouse, Toulouse, France
| | - Cindy Barnig
- INSERM, EFS BFC, LabEx LipSTIC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, Besançon, France; Service de Pneumologie, Oncologie thoracique et allergologie respiratoire, CHRU Besançon, Besançon, France
| | - Sylvie Leroy
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, CNRS UMR 7275 - FHU OncoAge, Service de Pneumologie Oncologie Thoracique et Soins Intensifs Respiratoires, CHU de Nice, Hôpital Pasteur, Nice, France
| | - Laurent Guilleminault
- Pôle des voies respiratoires, CHU de Toulouse, Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) INSERM UMR1291 - CNRS UMR5051 - Université Toulouse III, CRISALIS F-CRIN, Toulouse, France.
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Bourbeau J, Bhutani M, Hernandez P, Aaron SD, Beauchesne MF, Kermelly SB, D'Urzo A, Lal A, Maltais F, Marciniuk JD, Mulpuru S, Penz E, Sin DD, Van Dam A, Wald J, Walker BL, Marciniuk DD. 2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD. Chest 2023; 164:1159-1183. [PMID: 37690008 DOI: 10.1016/j.chest.2023.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
Chronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients.
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Affiliation(s)
- Jean Bourbeau
- Department of Medicine, McGill University Health Centre, McGill University, Montréal, QC, Canada.
| | - Mohit Bhutani
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shawn D Aaron
- The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Sophie B Kermelly
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Anthony D'Urzo
- Primary Care Lung Clinic, University of Toronto, Toronto, ON, Canada
| | - Avtar Lal
- Canadian Thoracic Society, Ottawa, ON, Canada
| | - François Maltais
- Department of Medicine, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Jeffrey D Marciniuk
- Respiratory Research Centre, University of Saskatchewan, Saskatoon, SK, Canada
| | - Sunita Mulpuru
- The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erika Penz
- Respiratory Research Centre, University of Saskatchewan, Saskatoon, SK, Canada
| | - Don D Sin
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Joshua Wald
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Brandie L Walker
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Darcy D Marciniuk
- Respiratory Research Centre, University of Saskatchewan, Saskatoon, SK, Canada
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Shibata Y, Kawayama T, Muro S, Sugiura H. Management goals and stable phase management of patients with chronic obstructive pulmonary disease in the Japanese respiratory society guideline for the management of chronic obstructive pulmonary disease 2022 (6th edition). Respir Investig 2023; 61:773-780. [PMID: 37741092 DOI: 10.1016/j.resinv.2023.08.007] [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] [Received: 06/05/2023] [Revised: 07/27/2023] [Accepted: 08/03/2023] [Indexed: 09/25/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by airflow obstruction on spirometry and symptoms such as dyspnea on exertion and chronic cough with sputum production, thus making it a significant healthcare issue worldwide. Japanese patients with COPD have unique characteristics compared to patients in Western countries, including older age and lower exacerbation frequency. The Japanese Respiratory Society (JRS) published the 6th edition of the COPD guideline in June 2022. This article introduces the management goals of COPD and describes its management during the stable phase, as outlined in the guideline. Management goals include improving the current status, such as the symptoms, quality of life (QOL), exercise tolerance, and physical activity, and reducing future risks through prevention of exacerbation and suppression of disease progression to prevent shortening of healthy life expectancy. Management plans should include avoidance of causative substances, assessment of disease severity, and personalized treatment plans. Pharmacotherapy using inhalation bronchodilators is a key component of the treatment of stable COPD. Bronchodilators, including short- and long-acting dilators, are commonly used to relieve symptoms and improve QOL. Inhaled corticosteroids (ICSs) are used in combination with long-acting bronchodilators, especially in patients with asthma and COPD overlap, or those experiencing frequent exacerbation of eosinophilia. Combination therapy with a long-acting muscarinic antagonist (LAMA), a long-acting beta 2 agonist (LABA), and ICS is expected to improve QOL and respiratory function and reduce mortality and exacerbation compared to the LAMA + LABA combination. Non-pharmacological therapies, including smoking cessation and pulmonary rehabilitation, should also be considered.
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Affiliation(s)
- Yoko Shibata
- Department of Pulmonary Medicine, Fukushima Medical University School of Medicine, Fukushima, 960-1295, Japan.
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Kurume, 830-0011, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University School of Medicine, Nara, 634-8521, Japan
| | - Hisatoshi Sugiura
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
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Strange C, Tkacz J, Schinkel J, Lewing B, Agatep B, Swisher S, Patel S, Edwards D, Touchette DR, Portillo E, Feigler N, Pollack M. Exacerbations and Real-World Outcomes After Single-Inhaler Triple Therapy of Budesonide/Glycopyrrolate/Formoterol Fumarate, Among Patients with COPD: Results from the EROS (US) Study. Int J Chron Obstruct Pulmon Dis 2023; 18:2245-2256. [PMID: 37849918 PMCID: PMC10577086 DOI: 10.2147/copd.s432963] [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: 08/05/2023] [Accepted: 10/01/2023] [Indexed: 10/19/2023] Open
Abstract
Purpose Triple therapy to prevent exacerbations from chronic obstructive pulmonary disease (COPD) is associated with improved health compared to single and dual-agent therapy in some populations. This study assessed the benefits of prompt administration of budesonide/glycopyrrolate/formoterol fumarate (BGF) following a COPD exacerbation. Patients and methods EROS was a retrospective analysis of people with COPD using the MORE2 Registry®. Inclusion required ≥1 severe, ≥2 moderate, or ≥1 moderate exacerbation while on other maintenance treatment. Within 12 months following the index exacerbation, ≥1 pharmacy claim for BGF was required. Primary outcomes were the rate of COPD exacerbations and healthcare costs for those that received BGF promptly (within 30 days of index exacerbation) versus delayed (31-180 days) and very delayed (181-365 days). The effect of each 30-day delay in initiation of BGF was estimated using a multivariable negative binomial regression model. Results 2409 patients were identified: 434 prompt, 1187 delayed, and 788 very delayed. The rate (95% CI) of total exacerbations post-index increased as time to BGF initiation increased: prompt 1.52 (1.39-1.66); delayed 2.00 (1.92-2.09); and very delayed 2.30 (2.20-2.40). Adjusting for patient characteristics, each 30-day delay in receiving BGF was associated with a 5% increase in the average number of subsequent exacerbations (rate ratio, 95% CI: 1.05, 1.01-1.08; p<0.05). Prompt initiation of BGF was also associated with lower post-index annualized COPD-related costs ($5002 for prompt vs $7639 and $8724 for the delayed and very delayed groups, respectively). Conclusion Following a COPD exacerbation, promptly initiating BGF was associated with a reduction in subsequent exacerbations and reduced healthcare utilization and costs.
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Affiliation(s)
- Charlie Strange
- College of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | - Sean Swisher
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Sushma Patel
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | | | - Daniel R Touchette
- College of Pharmacy - Pharmacy Systems Outcomes and Policy, University of Illinois Chicago, Chicago, IL, USA
| | - Edward Portillo
- Pharmacy Practice & Translational Research Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Norbert Feigler
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Michael Pollack
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
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50
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Singh D, Litewka D, Páramo R, Rendon A, Sayiner A, Tanni SE, Acharya S, Aggarwal B, Ismaila AS, Sharma R, Daley-Yates P. DElaying Disease Progression In COPD with Early Initiation of Dual Bronchodilator or Triple Inhaled PharmacoTherapy (DEPICT): A Predictive Modelling Approach. Adv Ther 2023; 40:4282-4297. [PMID: 37382864 PMCID: PMC10499693 DOI: 10.1007/s12325-023-02583-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Clinical studies demonstrate an accelerated decline in lung function in patients with moderate chronic obstructive pulmonary disease (COPD) (Global Initiative for Chronic Obstructive Lung Disease [GOLD] grade 2) versus severe and very severe COPD (GOLD grades 3 and 4). This predictive modelling study assessed the impact of initiating pharmacotherapy earlier versus later on long-term disease progression in COPD. METHODS The modelling approach used data on decline in forced expiratory volume in 1 s (FEV1) extracted from published studies to develop a longitudinal non-parametric superposition model of lung function decline with progressive impact of exacerbations from 0 per year to 3 per year and no ongoing pharmacotherapy. The model simulated decline in FEV1 and annual exacerbation rates from age 40 to 75 years in COPD with initiation of long-acting anti-muscarinic antagonist (LAMA)/long-acting beta2-agonist (LABA) (umeclidinium (UMEC)/vilanterol (VI)) or triple (inhaled corticosteroid (ICS)/LAMA/LABA; fluticasone furoate (FF)/UMEC/VI) therapy at 40, 55 or 65 years of age. RESULTS Model-predicted decline in FEV1 showed that, compared with 'no ongoing' therapy, initiation of triple or LAMA/LABA therapy at age 40, 55 or 65 years preserved an additional 469.7 mL or 236.0 mL, 327.5 mL or 203.3 mL, or 213.5 mL or 137.5 mL of lung function, respectively, by the age of 75. The corresponding average annual exacerbation rates were reduced from 1.57 to 0.91, 1.06 or 1.23 with triple therapy or to 1.2, 1.26 and 1.4 with LAMA/LABA therapy when initiated at 40, 55 or 65 years of age, respectively. CONCLUSIONS This modelling study suggests that earlier initiation of LAMA/LABA or triple therapy may have positive benefits in slowing disease progression in patients with COPD. Greater benefits were demonstrated with early initiation therapy with triple versus LAMA/LABA.
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Affiliation(s)
- Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Diego Litewka
- Pulmonology Unit, Hospital General de Agudos Dr. J. A. Fernández, Buenos Aires, Argentina
| | | | - Adrian Rendon
- Universidad Autónoma de Nuevo León, Servicio de Neumología, CIPTIR, Monterrey, NL, México
| | - Abdullah Sayiner
- Department of Chest Diseases, Ege University Faculty of Medicine, İzmir, Turkey
| | - Suzana E Tanni
- Department of Botucatu Medical School, Universidade Estadual Paulista, São Paulo, Brazil
| | | | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Peter Daley-Yates
- Clinical Pharmacology and Experimental Medicine, GSK, Brentford, London, UK.
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