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Barrecheguren M, Hidalgo PP, Gonçalves JMF, de Miguel Díez J. Diagnosis of Alpha-1 Antitrypsin Deficiency (AATD) in Primary Care. OPEN RESPIRATORY ARCHIVES 2024; 6:100310. [PMID: 38560506 PMCID: PMC10981108 DOI: 10.1016/j.opresp.2024.100310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Miriam Barrecheguren
- Servicio de Neumología, Hospital Vall d’Hebron, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | - Juan Marco Figueira Gonçalves
- Respiratory Department, Research Unit, University Hospital Nuestra Señora de Candelaria, Tenerife, Spain
- Canary Tropical Disease and Public Health Institute, La Laguna University, La Laguna, Spain
| | - 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
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Miravitlles M, Anzueto A, Barrecheguren M. Nine controversial questions about augmentation therapy for alpha-1 antitrypsin deficiency: a viewpoint. Eur Respir Rev 2023; 32:230170. [PMID: 38056890 DOI: 10.1183/16000617.0170-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/16/2023] [Indexed: 12/08/2023] Open
Abstract
Augmentation therapy with intravenous alpha-1 antitrypsin is the only specific treatment for alpha-1 antitrypsin deficiency (AATD)-associated emphysema. This treatment has been available and remained basically unchanged for more than 35 years, but many questions persist regarding its indications, regimen of administration and efficacy. Because AATD is a rare disease, it has not been possible to conduct randomised, placebo-controlled trials that are adequately powered for the usual outcomes analysed in non-AATD-related COPD, such as lung function decline, exacerbations, symptoms or quality of life. New outcomes such as lung densitometry measured by computed tomography are more sensitive for identifying emphysema progression but are not widely accepted by regulatory agencies. In addition, clinical manifestations, severity and the natural history of lung disease associated with AATD are very heterogeneous, which means that individual prediction of prognosis is challenging. Therefore, the indication for augmentation is sometimes a dilemma between initiating treatment in individuals who may not develop significant lung disease or in whom disease will not progress and delaying it in patients who will otherwise rapidly and irreversibly progress.Other areas of debate are the possible indication for augmentation in patients with severe AATD and respiratory diseases other than emphysema, such as bronchiectasis or asthma, and the use of therapy after lung transplant in AATD patients. All these uncertainties imply that the indication for treatment must be personalised in expert reference centres after in-depth discussion of the pros and cons of augmentation with the patient.
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Affiliation(s)
- Marc Miravitlles
- Pneumology 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
| | - Antonio Anzueto
- Pulmonary Disease/Critical Care, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Miriam Barrecheguren
- Pneumology 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
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Tural Onur S, Natoli A, Dreger B, Arınç S, Sarıoğlu N, Çörtük M, Karadoğan D, Şenyiğit A, Yıldız BP, Köktürk N, Argun Barıs S, Kodalak Cengiz S, Polatli M. An Alpha-1 Antitrypsin Deficiency Screening Study in Patients with Chronic Obstructive Pulmonary Disease, Bronchiectasis, or Asthma in Turkey. Int J Chron Obstruct Pulmon Dis 2023; 18:2785-2794. [PMID: 38046982 PMCID: PMC10693271 DOI: 10.2147/copd.s425835] [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: 06/14/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Alpha-1 antitrypsin deficiency (AATD) is a rare hereditary condition characterized by decreased serum alpha-1 antitrypsin (AAT) levels. We aim to identify AATD in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, or asthma and to report the frequency of AAT variants in Turkey. Patients and Methods This non-interventional, multicenter, prospective study was conducted between October 2021 and June 2022. Adult patients with COPD, bronchiectasis, asthma, liver symptoms, or family members with AATD were included. Demographic and clinical characteristics, pulmonary diagnosis, respiratory symptoms, and AAT serum levels were assessed. Whole blood samples were collected as dried blood spots, and the most common AATD mutations were simultaneously tested by allele-specific genotyping. Results A total of 1088 patients, mainly diagnosed with COPD (92.7%) and shortness of breath (78.7%), were assessed. Fifty-one (5%) were found to have AATD mutations. Fifteen (29.4%) patients had Pi*S or Pi*Z mutations, whereas 36 (70.6%) patients carried rare alleles Pi*M malton (n=18, 35.3% of mutations), Pi*I (n=8, 16%), Pi*P lowell (n=7, 14%), Pi*M heerlen (n=2, 4%), and Pi*S iiyama (n=1, 2%). The most common heterozygous combinations were Pi*M/Z (n=12, 24%), and Pi*M/M malton (n=11, 22%). Ten patients with severe AATD due to two deficiency alleles were identified, two with the Pi*Z/Z genotype, four with the genotype Pi*M malton/M malton, three with Pi*Z/M malton, and one with Pi*Z/M heerlen. Conclusion Our results identified AATD mutations as a genetic-based contributor to lung disease in patients with COPD or bronchiectasis and assessed their frequency in a population of Turkish patients.
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Affiliation(s)
- Seda Tural Onur
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Antonino Natoli
- Scientific and Medical Affairs, Scientific Innovation Office, Grifols, Frankfurt, Deutschland
| | - Bettina Dreger
- Scientific and Medical Affairs, Scientific Innovation Office, Grifols, Frankfurt, Deutschland
| | - Sibel Arınç
- Clinic of Chest Diseases, University of Health Sciences Turkey, S.B.Ü. Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Türkiye
| | - Nurhan Sarıoğlu
- Department of Pulmonology, Balıkesir University Faculty of Medicine, Pulmonology Clinic, Balıkesir, Türkiye
| | - Mustafa Çörtük
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Dilek Karadoğan
- Department of Chest Diseases, Recep Tayyip Erdoğan University, School of Medicine, Rize, Türkiye
| | - Abdurrahman Şenyiğit
- Department of Chest Diseases, Dicle University Faculty of Medicine Hospital, Diyarbakır, Türkiye
| | - Birsen Pınar Yıldız
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Nurdan Köktürk
- Department of Pulmonary Medicine, Gazi University, School of Medicine, Ankara, Türkiye
| | - Serap Argun Barıs
- Department of Pulmonary Diseases, Faculty of Medicine, Kocaeli University, Kocaeli, Türkiye
| | | | - Mehmet Polatli
- Faculty of Medicine, Aydin Adnan Menderes University, Aydin, Türkiye
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Mornex JF, Traclet J, Guillaud O, Dechomet M, Lombard C, Ruiz M, Revel D, Reix P, Cottin V. Alpha1-antitrypsin deficiency: An updated review. Presse Med 2023; 52:104170. [PMID: 37517655 DOI: 10.1016/j.lpm.2023.104170] [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] [Received: 03/17/2023] [Revised: 05/07/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023] Open
Abstract
Alpha1-antitrypsin deficiency (AATD) is a rare autosomal recessive disease associated with the homozygous Z variant of the SERPINA1 gene. Clinical expression of AATD, reported 60 years ago associate a severe deficiency, pulmonary emphysema and/or liver fibrosis. Pulmonary emphysema is due to the severe alpha1-antitrypsin deficiency of the ZZ homozygous status and is favored by smoking. Liver fibrosis is due to the ZZ homozygous status and is favored by obesity and excessive chronic alcohol intake, with a risk of liver cancer. Diagnosis is based on serum level and either isoelectric focusing determination of the biochemical phenotype or PCR detection of some variants. SERPINA1 gene sequencing is necessary in case of discrepancies between the results of these tests. No treatment is available for the liver disease in AATD. Although no specific trial has been performed, COPD in AATD should be treated as per COPD recommendations. Based on a randomized clinical trial, augmentation therapy is indicated in non-smoking adults less than 70 years of age with emphysema at chest CT, confirmed homozygous AATD, and FEV1 between 35% and 70% of predicted. In contrast Z heterozygosis (MZ or SZ) brings a risk of lung or liver disease only in association with further risk factors. Early detection, in all patients with COPD and chronic liver disease, is critical for the correct information of Z variant carriers. News ways of correcting the liver production of alpha1-antitrypsin will modify the care of AATD patients.
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Affiliation(s)
- Jean-François Mornex
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, F-69007 Lyon, France; Centre de référence des maladies pulmonaires rares, Orphalung, RESPIFIL, ERN-LUNG, F-69500 Bron, France; Hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, F-69500 Bron, France; Inserm, hospices civils de Lyon, CIC 1407, F-69500 Bron, France.
| | - Julie Traclet
- Centre de référence des maladies pulmonaires rares, Orphalung, RESPIFIL, ERN-LUNG, F-69500 Bron, France; Hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, F-69500 Bron, France
| | - Olivier Guillaud
- Ramsay générale de santé, clinique de la Sauvegarde, F-69009 Lyon, France; Hospices civils de Lyon, hôpital Edouard Herriot, Fédération des spécialités digestives, F-69003 Lyon, France
| | - Magali Dechomet
- Hospices civils de Lyon, hôpital Lyon sud, service d'immunologie biologique, F-69495 Pierre Bénite, France
| | - Christine Lombard
- Hospices civils de Lyon, hôpital Lyon sud, service d'immunologie biologique, F-69495 Pierre Bénite, France
| | - Mathias Ruiz
- Centre de référence de l'atrésie des voies biliaires et des cholestases génétiques, FILFOIE, F-69500 Bron, France; Hospices civils de Lyon, hôpital femme mère enfant, service d'hépatologie, gastroentérologie et nutrition pédiatrique, F-69500 Bron, France
| | - Didier Revel
- Hospices civils de Lyon, hôpital Louis Pradel, service d'imagerie, F-69500 Bron, France
| | - Philippe Reix
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant. Hospices civils de Lyon, F-69500 Bron, France; Université de Lyon, université Lyon, CNRS, UMR 5558, équipe EMET, F-69100 Villeurbanne, France
| | - Vincent Cottin
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, F-69007 Lyon, France; Centre de référence des maladies pulmonaires rares, Orphalung, RESPIFIL, ERN-LUNG, F-69500 Bron, France; Hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, F-69500 Bron, France
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Feitosa PH. Diagnosis and augmentation therapy for alpha-1 antitrypsin deficiency: current knowledge and future potential. Drugs Context 2023; 12:2023-3-1. [PMID: 37521109 PMCID: PMC10379007 DOI: 10.7573/dic.2023-3-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
The underdiagnosis of alpha-1 antitrypsin (AAT) deficiency (AATD) has been recognized for many years, yet little progress has been made in treatment of the disease. In this review, we summarize the AATD disease process as well as its diagnosis and treatment by AAT augmentation therapy. AATD is a rare autosomal disease that primarily affects the lungs and liver. AATD is associated with an increased susceptibility to developing pulmonary emphysema. The specific pharmacological treatment for AATD is intravenous administration of exogenous AAT. Augmentation therapy with AAT increases serum and pulmonary epithelial AAT levels, restores anti-elastase capacity, and decreases inflammatory mediators in the lung. Augmentation therapy reduces the loss of lung density over time, thus slowing progression of the disease. The effects of augmentation therapy on outcomes, such as frequency/duration of flare-ups, quality of life, lung function decline and mortality, are assessed. Wider testing for AATD, potentially through primary care physicians, could result in earlier treatment and better outcomes for individuals with AATD-induced lung respiratory disease.
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Barrecheguren M, Miravitlles M. Cancer risk associated with alpha-1-antitrypsin deficiency: only large registries will give us the answer. Eur Respir J 2022; 60:60/4/2201289. [DOI: 10.1183/13993003.01289-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/30/2022] [Indexed: 11/05/2022]
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Torres-Durán M, López-Campos JL, Rodríguez-Hermosa JL, Esquinas C, Martínez-González C, Hernández-Pérez JM, Rodríguez C, Bustamante A, Casas-Maldonado F, Barrecheguren M, González C, Miravitlles M. Demographic and clinical characteristics of patients with alpha-1 antitrypsin deficiency genotypes PI*ZZ and PI*SZ in the Spanish registry of EARCO. ERJ Open Res 2022; 8:00213-2022. [PMID: 36171983 PMCID: PMC9511153 DOI: 10.1183/23120541.00213-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Spanish registry of α1-antitrypsin deficiency (AATD) integrated in the European Alpha-1 Research Collaboration (EARCO) provides information about the characteristics of patients, in particular those with the PI*SZ genotype, which is frequent in Spain. Method Individuals with severe AATD defined as proteinase inhibitor (PI) genotypes PI*ZZ, PI*SZ and other rare deficient variants were included from February 1, 2020, to February 1, 2022. The analysis focused on a comparison of the characteristics of PI*ZZ and PI*SZ patients. Results 409 patients were included (53.8% men) with a mean±sd age of 53.5±15.9 years. Genotypes were PI*ZZ in 181 (44.7%), PI*SZ in 163 (40.2%), PI*SS in 29 (7.2%) and other in 32 (7.9%). 271 (67.4%) had lung disease: 175 chronic obstructive pulmonary disease (43.5%), 163 emphysema (40.5%) and 83 bronchiectasis (20.6%). Patients with the PI*SZ genotype were younger, more frequently non-index cases and had a lower frequency of respiratory diseases except asthma compared with PI*ZZ patients. Among patients with respiratory diseases, PI*SZ individuals were significantly older both at onset of symptoms and at diagnosis; only asthma was more frequent in PI*SZ than in PI*ZZ individuals. Twelve PI*SZ patients (15.4%) received augmentation therapy compared with 94 PI*ZZ patients (66.2%; p<0.001). Conclusions There is a high prevalence of PI*SZ in Spain. Patients with the PI*SZ genotype were older at symptom onset and diagnosis and had less severe lung disease compared with PI*ZZ patients. The prevalence of asthma was higher in PI*SZ, and up to 15% of PI*SZ patients received augmentation therapy. Patients with the PI*ZZ genotype have more severe pulmonary disease than those with the PI*SZ genotype. However, asthma is as frequent in PI*SZ as in PI*ZZ.https://bit.ly/3m10MNN
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Greulich T, Albert A, Cassel W, Boeselt T, Peychev E, Klemmer A, Ferreira F, Clarenbach C, Torres-Duran ML, Turner AM, Miravitlles M. Opinions and Attitudes of Pulmonologists About Augmentation Therapy in Patients with Alpha-1 Antitrypsin Deficiency. A Survey of the EARCO Group. Int J Chron Obstruct Pulmon Dis 2022; 17:53-64. [PMID: 35023913 PMCID: PMC8743984 DOI: 10.2147/copd.s346051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Augmentation therapy (AT) is the only specific treatment licensed for patients with alpha-1 antitrypsin deficiency (AATD) associated lung disease. Since patients with severe AATD may have a very different prognosis and AT requires intravenous infusions for life, the decision to initiate AT may be challenging. Methods This survey was conducted on 63 experts in AATD from 13 European countries about their opinions and attitudes regarding AT. Participants were asked to rank the importance of 11 identified factors related with the prescription of AT. In addition, each participant was asked to respond to the indication of AT for 30 out of 500 hypothetical cases developed with the combinations of the 11 factors. Each case was evaluated by 3 experts to check the concordance. Results The variables that scored higher on preferences for initiating AT were AAT genotype (score 8.6 from a Likert scale 0–10 (SD: 1.7)), AATD serum level (8.2 (SD:2.4)) and FEV1 (%) decline (7.9 (SD:2.4)). Among the 500 different cases, there was an agreement in indication of AT among the 3 experts in 291 (58.2%). Regarding the variables associated with AT, it was indicated to 81.9% of Pi*ZZ, 52.4% of Pi*SZ and 9.8% of Pi*MZ (p < 0.0001). For Pi*ZZ patients, multivariate analysis identified younger age, reduced FEV1 (%), higher FEV1 decline and worse emphysema as significantly associated with prescription (AUC = 0.8114); for Pi*SZ variables were younger age, worse FEV1 (%) and worse emphysema (AUC = 0.7414); and for Pi*MZ younger age, worse DLCO (%), higher DLCO decline and dyspnea (AUC = 0.8387). Conclusion There is a high variability in the criteria for prescription of AT among European experts. Most cases were recommended AT according to guidelines, but a significant number of patients with genotype Pi*SZ and almost 10% Pi*MZ were recommended to initiate AT despite the lack of evidence of efficacy in these genotypes.
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Affiliation(s)
- Timm Greulich
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Anna Albert
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Werner Cassel
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Sleep Disorders Centre, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Tobias Boeselt
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Erika Peychev
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Andreas Klemmer
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | | | | | - Maria L Torres-Duran
- Pneumology Department, Hospital Álvaro Cunqueiro, AS Vigo, Spain.,Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Alice M Turner
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marc Miravitlles
- Pneumology 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
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Miravitlles M, Calle M, Molina J, Almagro P, Gómez JT, Trigueros JA, Cosío BG, Casanova C, López-Campos JL, Riesco JA, Simonet P, Rigau D, Soriano JB, Ancochea J, Soler-Cataluña JJ. [Translated article] Spanish COPD guidelines (GesEPOC) 2021: Updated pharmacological treatment of stable COPD. Arch Bronconeumol 2022. [DOI: 10.1016/j.arbres.2021.03.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Miravitlles M, Calle M, Molina J, Almagro P, Gómez JT, Trigueros JA, Cosío BG, Casanova C, López-Campos JL, Riesco JA, Simonet P, Rigau D, Soriano JB, Ancochea J, Soler-Cataluña JJ. Spanish COPD Guidelines (GesEPOC) 2021: Updated Pharmacological treatment of stable COPD. Arch Bronconeumol 2022; 58:69-81. [PMID: 33840553 DOI: 10.1016/j.arbres.2021.03.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 01/16/2023]
Abstract
The Spanish COPD Guidelines (GesEPOC) were first published in 2012, and since then have undergone a series of updates incorporating new evidence on the diagnosis and treatment of COPD. GesEPOC was drawn up in partnership with scientific societies involved in the treatment of COPD and the Spanish Patients' Forum. Their recommendations are based on an evaluation of the evidence using GRADE methodology, and a narrative description of the evidence in areas in which GRADE cannot be applied. In this article, we summarize the recommendations on the pharmacological treatment of stable COPD based on 9 PICO questions. COPD treatment is a 4-step process: 1) diagnosis, 2) determination of the risk level, 3) initial and subsequent inhaled therapy, and 4) identification and management of treatable traits. For the selection of inhaled therapy, high-risk patients are divided into 3 phenotypes: non-exacerbator, eosinophilic exacerbator, and non-eosinophilic exacerbator. Some treatable traits are general and should be investigated in all patients, such as smoking or inhalation technique, while others affect severe patients in particular, such as chronic hypoxemia and chronic bronchial infection. COPD treatment is based on long-acting bronchodilators with single agents or in combination, depending on the patient's risk level. Eosinophilic exacerbators must receive inhaled corticosteroids, while non-eosinophilic exacerbators require a more detailed evaluation to choose the best therapeutic option. The new GesEPOC also includes recommendations on the withdrawal of inhaled corticosteroids and on indications for alpha-1 antitrypsin treatment. GesEPOC offers a more individualized approach to COPD treatment tailored according to the clinical characteristics of patients and their level of complexity.
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Affiliation(s)
- Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos. Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | | | - Pere Almagro
- Servicio de Medicina Interna, Hospital Universitario Mutua de Terrassa, Terrassa, España
| | | | | | - Borja G Cosío
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, España
| | - Ciro Casanova
- Servicio de Neumología-Unidad de Investigación, Hospital Universitario Nuestra Señora de La Candelaria. Universidad de La Laguna, Tenerife, España
| | - José Luis López-Campos
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, España
| | - Juan Antonio Riesco
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, España
| | - Pere Simonet
- Centro de Salud Viladecans-2, Atención Primaria Costa de Ponent-Institut Català de la Salut. Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Departament de Ciències Clíniques, Universitat Barcelona, Barcelona, España
| | - David Rigau
- Centro Cochrane Iberoamericano, Barcelona, España
| | - Joan B Soriano
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario de La Princesa. Universidad Autónoma de Madrid, Madrid, España
| | - Julio Ancochea
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario de La Princesa. Universidad Autónoma de Madrid, Madrid, España
| | - Juan José Soler-Cataluña
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Arnau de Vilanova-Lliria, Valencia, España
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Gonzalez A, Belmonte I, Nuñez A, Farago G, Barrecheguren M, Pons M, Orriols G, Gabriel-Medina P, Rodríguez-Frías F, Miravitlles M, Esquinas C. New variants of alpha-1-antitrypsin: structural simulations and clinical expression. Respir Res 2022; 23:339. [PMID: 36496391 PMCID: PMC9741788 DOI: 10.1186/s12931-022-02271-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is characterized by reduced serum levels of the AAT protein and predisposes to liver and lung disease. The characterization at structural level of novel pathogenic SERPINA1 mutants coding for circulating AAT could provide novel insights into the mechanisms of AAT misfolding. The present study aimed to provide a practical framework for the identification and analysis of new AAT mutations, combining structural simulations and clinical data. METHODS We analysed a total of five mutations (four not previously described) in a total of six subjects presenting moderate to severe AATD: Gly95Alafs*18, Val210Glu, Asn247Ser, Pi*S + Asp341His and Pi*S + Leu383Phe + Lys394Ile. Clinical data, genotyping and phenotyping assays, structural mapping, and conformational characterization through molecular dynamic (MD) simulations were developed and combined. RESULTS Newly discovered AAT missense variants were localized both on the interaction surface and the hydrophobic core of the protein. Distribution of mutations across the structure revealed Val210Glu at the solvent exposed s4C strand and close to the "Gate" region. Asn247Ser was located on the accessible surface, which is important for glycan attachment. On the other hand, Asp341His, Leu383Phe were mapped close to the "breach" and "shutter" regions. MD analysis revealed the reshaping of local interactions around the investigated substitutions that have varying effects on AAT conformational flexibility, hydrophobic packing, and electronic surface properties. The most severe structural changes were observed in the double- and triple-mutant (Pi*S + Asp341His and Pi*S + Leu383Phe + Lys394Ile) molecular models. The two carriers presented impaired lung function. CONCLUSIONS The results characterize five variants, four of them previously unknown, of the SERPINA1 gene, which define new alleles contributing to the deficiency of AAT. Rare variants might be more frequent than expected, and therefore, in discordant cases, standardized screening of the S and Z alleles needs complementation with gene sequencing and structural approaches. The utility of computational modelling for providing supporting evidence of the pathogenicity of rare single nucleotide variations is discussed.
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Affiliation(s)
- Angel Gonzalez
- grid.7080.f0000 0001 2296 0625Department of Computational Medicine, Statistic Unit, Medicine Faculty, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Irene Belmonte
- grid.411083.f0000 0001 0675 8654Department of Clinical Biochemistry, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Alexa Nuñez
- grid.411083.f0000 0001 0675 8654Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, P. Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Georgina Farago
- grid.411083.f0000 0001 0675 8654Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, P. Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Miriam Barrecheguren
- grid.411083.f0000 0001 0675 8654Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, P. Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Mònica Pons
- grid.411083.f0000 0001 0675 8654Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Gerard Orriols
- grid.411083.f0000 0001 0675 8654Department of Clinical Biochemistry, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Pablo Gabriel-Medina
- grid.411083.f0000 0001 0675 8654Department of Clinical Biochemistry, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francisco Rodríguez-Frías
- grid.411083.f0000 0001 0675 8654Department of Clinical Biochemistry, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain ,grid.7080.f0000 0001 2296 0625Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain ,grid.452371.60000 0004 5930 4607Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, (CIBEREHD), Barcelona, Spain ,grid.430994.30000 0004 1763 0287Clinical Biochemistry Research Group/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Marc Miravitlles
- grid.411083.f0000 0001 0675 8654Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, P. Vall d’Hebron 119-129, 08035 Barcelona, Spain ,grid.512891.6Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Cristina Esquinas
- grid.411083.f0000 0001 0675 8654Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, P. Vall d’Hebron 119-129, 08035 Barcelona, Spain ,grid.5841.80000 0004 1937 0247Public Health, Mental, Maternal and Child Health Nursing Departament, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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12
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Domínguez-González C, Madruga-Garrido M, Hirano M, Martí I, Martín MA, Munell F, Nascimento A, Olivé M, Quan J, Sardina MD, Martí R, Paradas C. Collaborative model for diagnosis and treatment of very rare diseases: experience in Spain with thymidine kinase 2 deficiency. Orphanet J Rare Dis 2021; 16:407. [PMID: 34600563 PMCID: PMC8487573 DOI: 10.1186/s13023-021-02030-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/18/2021] [Indexed: 11/22/2022] Open
Abstract
Background Mitochondrial diseases are difficult to diagnose and treat. Recent advances in genetic diagnostics and more effective treatment options can improve patient diagnosis and prognosis, but patients with mitochondrial disease typically experience delays in diagnosis and treatment. Here, we describe a unique collaborative practice model among physicians and scientists in Spain focused on identifying TK2 deficiency (TK2d), an ultra-rare mitochondrial DNA depletion and deletions syndrome.
Main Body This collaboration spans research and clinical care, including laboratory scientists, adult and pediatric neuromuscular clinicians, geneticists, and pathologists, and has resulted in diagnosis and consolidation of care for patients with TK2d. The incidence of TK2d is not known; however, the first clinical cases of TK2d were reported in 2001, and only ~ 107 unique cases had been reported as of 2018. This unique collaboration in Spain has led to the diagnosis of more than 30 patients with genetically confirmed TK2d across different regions of the country. Research affiliate centers have led investigative treatment with nucleosides based on understanding of TK2d clinical manifestations and disease mechanisms, which resulted in successful treatment of a TK2d mouse model with nucleotide therapy in 2010. Only 1 year later, this collaboration enabled rapid adoption of treatment with pyrimidine nucleotides (and later, nucleosides) under compassionate use. Success in TK2d diagnosis and treatment in Spain is attributable to two important factors: Spain’s fully public national healthcare system, and the designation in 2015 of major National Reference Centers for Neuromuscular Disorders (CSURs). CSUR networking and dissemination facilitated development of a collaborative care network for TK2d disease, wherein participants share information and protocols to request approval from the Ministry of Health to initiate nucleoside therapy. Data have recently been collected in a retrospective study conducted under a Good Clinical Practice–compliant protocol to support development of a new therapeutic approach for TK2d, a progressive disease with no approved therapies. Conclusions The Spanish experience in diagnosis and treatment of TK2d is a model for the diagnosis and development of new treatments for very rare diseases within an existing healthcare system.
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Affiliation(s)
- Cristina Domínguez-González
- Neuromuscular Disorders Unit, Neurology Department, Hospital 12 de Octubre, Madrid, Spain.,Instituto de Investigación imas12, Hospital 12 de Octubre, Madrid, Spain.,Center for Biomedical Network Research On Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Michio Hirano
- Neurology Department, H. Houston Merritt Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Itxaso Martí
- Pediatric Department, Donostia University Hospital, Biodonostia Health Research Institute, University of the Basque Country, San Sebastián, Spain
| | - Miguel A Martín
- Center for Biomedical Network Research On Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain.,Mitochondrial Diseases Laboratory, Department of Biochemistry, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Francina Munell
- Pediatric Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Andrés Nascimento
- Center for Biomedical Network Research On Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain.,Pediatric Department, Vall d'Hebron Hospital, Barcelona, Spain.,Neuromuscular Unit, Neurology Department, Sant Joan de Déu Research Institute, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Montse Olivé
- Neuromuscular Disorders Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau/Center for Biomedical Network Research On Rare Diseases (CIBERER), Barcelona, Spain
| | | | - M Dolores Sardina
- Pediatric Neurology Department, Badajoz Hospital Complex, Badajoz, Spain
| | - Ramon Martí
- Center for Biomedical Network Research On Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain.,Research Group On Neuromuscular and Mitochondrial Diseases, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Carmen Paradas
- Neurology Department, Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla, Avd. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Center for Biomedical Network Research On Neurodegenerative Disorders (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain.
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13
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Martinez-González C, Blanco I, Diego I, Bueno P, Miravitlles M. Estimated Prevalence and Number of PiMZ Genotypes of Alpha-1 Antitrypsin in Seventy-Four Countries Worldwide. Int J Chron Obstruct Pulmon Dis 2021; 16:2617-2630. [PMID: 34556982 PMCID: PMC8455519 DOI: 10.2147/copd.s327803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/03/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The α-1 antitrypsin (AAT) protease inhibitor PiMZ is a moderately deficient genotype, until recently considered of little or negligible risk. However, a growing number of studies show that MZ carriers have an increased risk of developing lung and liver diseases, if exposed to smoking or other airborne or industrial pollutants, and hepatotoxic substances. METHODS We used the epidemiological studies performed to determine the frequencies of PiM and PiZ worldwide, based on the following criteria: 1) samples representative of the general population; 2) AAT phenotyping or genotyping characterized by adequate methods, including isoelectric focusing and polymerase chain reaction; and 3) studies with reliable results assessed with a coefficient of variation calculated from the sample size and 95% confidence intervals, to measure the precision of the results in terms of dispersion of the data around the mean. RESULTS The present review reveals an impressive number of MZs of more than 35 million in 74 countries of the world with available data. Seventy-five percent of them are people of Caucasian European heritage, mostly living in Europe, America, Australia and New Zealand. Twenty percent of the remaining MZs live in Asia, with the highest concentrations in the Middle East, Eastern¸ Southern, and South-eastern regions of the Asian continent. The remaining five percent are Africans residing in Western and Eastern Africa. CONCLUSION Considering the high rate of smoking, the outdoor and the indoor air pollution from solid fuels used in cooking and heating, and the exposure to industrial dusts and chemicals in many of these countries, these figures are very worrying, and hence the importance of adequately assessing MZ subjects, recommending them rigorous preventive measures based on the adoption of healthy lifestyles, including avoidance of smoking and alcohol.
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Affiliation(s)
- Cristina Martinez-González
- Pulmonology Department, University Central Hospital of Asturias, Universidad de Oviedo, Instituto de Investigación del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ignacio Blanco
- Alpha1-Antitrypsin Deficiency Spanish Registry (REDAAT), Spanish Society of Pneumology and Thoracic Surgery (SEPAR), Barcelona, Spain
| | - Isidro Diego
- Materials and Energy Department, School of Mining Engineering, Oviedo University, Oviedo, Spain
| | - Patricia Bueno
- Internal Medicine Department, County Hospital of Jarrio, Jarrio, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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14
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Núñez A, Belmonte I, Miranda E, Barrecheguren M, Farago G, Loeb E, Pons M, Rodríguez-Frías F, Gabriel-Medina P, Rodríguez E, Genescà J, Miravitlles M, Esquinas C. Association between circulating alpha-1 antitrypsin polymers and lung and liver disease. Respir Res 2021; 22:244. [PMID: 34526035 PMCID: PMC8442448 DOI: 10.1186/s12931-021-01842-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/08/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is considered one of the most common genetic diseases and is characterised by the misfolding and polymerisation of the alpha-1 antitrypsin (AAT) protein within hepatocytes. The relevance of circulating polymers (CP) of AAT in the pathogenesis of lung and liver disease is not completely understood. Therefore, the main objective of our study was to determine whether there is an association between the levels of CP of AAT and the severity of lung and liver disease. METHOD This was a cross-sectional study in patients with different phenotypes of AATD and controls. To quantify CP, a sandwich ELISA was performed using the 2C1 monoclonal antibody against AAT polymers. Sociodemographic data, clinical characteristics, and liver and lung parameters were collected. RESULTS A cohort of 70 patients was recruited: 32 Pi*ZZ (11 on augmentation therapy); 29 Z-heterozygous; 9 with other genotypes. CP were compared with a control group of 47 individuals (35 Pi*MM and 12 Pi*MS). ZZ patients had the highest concentrations of CP (p < 0.001) followed by Z heterozygous. The control group and patients with Pi*SS and Pi*SI had the lowest CP concentrations. Pi*ZZ also had higher levels of liver stiffness measurements (LSM) than the remaining AATD patients. Among patients with one or two Z alleles, two patients with lung and liver impairment showed the highest concentrations of CP (47.5 µg/mL), followed by those with only liver abnormality (n = 6, CP = 34 µg/mL), only lung (n = 18, CP = 26.5 µg/mL) and no abnormalities (n = 23, CP = 14.3 µg/mL). Differences were highly significant (p = 0.004). CONCLUSIONS Non-augmented Pi*ZZ and Z-patients with impaired lung function and increased liver stiffness presented higher levels of CP than other clinical phenotypes. Therefore, CP may help to identify patients more at risk of developing lung and liver disease and may provide some insight into the mechanisms of disease.
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Affiliation(s)
- Alexa Núñez
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, 08193, Barcelona, Spain
| | - Irene Belmonte
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Elena Miranda
- Department of Biology and Biotechnologies, 'Charles Darwin' and Pasteur Institute - Cenci Bolognetti Foundation, Sapienza University of Rome, Rome, Italy
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Georgina Farago
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Eduardo Loeb
- Pneumology Department, Teknon Medical Center, Barcelona, Spain
| | - Mònica Pons
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francisco Rodríguez-Frías
- Universitat Autònoma de Barcelona, Bellaterra, 08193, Barcelona, Spain
- Department of Clinical Biochemistry, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, (CIBEREHD), Barcelona, Spain
- Clinical Biochemistry Research Group/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Pablo Gabriel-Medina
- Department of Clinical Biochemistry, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Esther Rodríguez
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Genescà
- Universitat Autònoma de Barcelona, Bellaterra, 08193, Barcelona, Spain
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, (CIBEREHD), Barcelona, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Universitat Autònoma de Barcelona, Bellaterra, 08193, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
| | - Cristina Esquinas
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, 08193, Barcelona, Spain
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Spanish COPD guidelines (GesEPOC) 2021: Updated pharmacological treatment of stable COPD. ACTA ACUST UNITED AC 2021. [DOI: 10.1016/j.arbr.2021.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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