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Keeratichananont W, Kaenmuang P, Geater SL, Denyuk R, Kanchanakanok C. Correlation of fractional exhaled nitric oxide (FeNO) and clinical outcomes in patients with chronic obstructive pulmonary disease: A prospective cohort study. Respir Med 2024; 229:107682. [PMID: 38815659 DOI: 10.1016/j.rmed.2024.107682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is an acceptable and noninvasive marker for defining eosinophilic airway inflammation. Further study is necessary to clarify the role of FeNO in patients with chronic obstructive pulmonary disease (COPD). This study aimed to determine the association between FeNO levels and clinical outcomes. METHODS A prospective observational study was conducted at Songklanagarind Hospital from October 2020 to November 2022. FeNO testing and spirometry were performed at the initial visit and 12-month follow-up. Exacerbation, hospitalization, lung function decline, and all-cause mortality were analyzed to determine the association between FeNO levels and clinical outcomes. RESULTS A total of 60 patients with COPD were enrolled, 88.3 % of whom were male, with a mean age of 71.3 ± 9.5 years. There were 18 patients (30 %) in the high FeNO group (≥25 ppb) and 42 patients (70 %) in the low (<25 ppb) FeNO group. The mean blood eosinophil count (BEC) was significantly higher in the high FeNO group (p < 0.001). After a 12-month follow-up period, high FeNO group had higher exacerbation events (HR of 1.26, 95 % confidence interval (CI), 1.10-1.97, p= 0.025). Hospitalization and mortality rates were significantly higher in the high FeNO group. Regardless of the inhaled corticosteroids used, patients with high BEC and FeNO levels tended to have a greater risk of exacerbation. CONCLUSION In patients with COPD, FeNO levels are strongly correlated with BEC. Poor clinical outcomes were reported in patients with high FeNO levels. FeNO may be a useful biomarker for predicting clinical outcomes in patients with COPD.
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Affiliation(s)
- Warangkana Keeratichananont
- Respiratory and Respiratory Critical Care Medicine Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Punchalee Kaenmuang
- Respiratory and Respiratory Critical Care Medicine Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand.
| | - Sarayut Lucien Geater
- Respiratory and Respiratory Critical Care Medicine Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Ratikorn Denyuk
- Respiratory and Respiratory Critical Care Medicine Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Chitsanupong Kanchanakanok
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Allinson JP, Vlies BH, Brill SE, Law M, Burnside G, Finney LJ, Alves-Moreira L, Donaldson GC, Calverley PMA, Walker PP, Wedzicha JA. A Double-Blind, Randomized, Placebo-controlled Trial of Long-Term Doxycycline Therapy on Exacerbation Rate in Patients with Stable Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2023; 208:549-558. [PMID: 37450935 PMCID: PMC10492249 DOI: 10.1164/rccm.202212-2287oc] [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: 12/19/2022] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) exacerbations are a major cause of morbidity and mortality, and preventing them is a key treatment target. Long-term macrolide treatment is effective at reducing exacerbations, but there is a paucity of evidence for other antibiotic classes. Objectives: To assess whether 12-month use of doxycycline reduces the exacerbation rate in people with COPD. Methods: People with moderate to very severe COPD and an exacerbation history were recruited from three UK centers and randomized to 12 months of doxycycline 100 mg once daily or placebo. The primary study outcome was the exacerbation rate per person-year. Results: A total of 222 people were randomized. Baseline mean FEV1 was 1.35 L (SD, 0.35 L), 52.5% predicted (SD, 15.9% predicted). The median number of treated exacerbations in the year before the study was 2 (SD, 1-4). A total of 71% of patients reported two or more exacerbations, and 81% were already prescribed inhaled corticosteroids at baseline. The COPD exacerbation rate did not differ between the groups (doxycycline/placebo rate ratio [RR], 0.86; 95% confidence interval [CI], 0.67-1.10; P = 0.23). No difference was seen if only treated exacerbations or hospitalizations were considered. In preplanned subgroup analysis, doxycycline appeared to better reduce the exacerbation rate among people with severe COPD (RR, 0.36; 95% CI, 0.15-0.85; P = 0.019) and in those with an eosinophil count <300 cells/μl (RR, 0.50; 95% CI, 0.29-0.84; P = 0.01). Health status measured by St. George's Respiratory Questionnaire was 5.2 points worse in the doxycycline group at 12 months (P < 0.007). Conclusions: Doxycycline did not significantly reduce the exacerbation rate, over 12 months, in participants with COPD who exacerbated regularly, but it may have benefitted those with more severe COPD or blood eosinophil counts <300 cells/μl. Clinical trial registered with www.clinicaltrials.gov (NCT02305940).
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Affiliation(s)
- James P. Allinson
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | | | - Simon E. Brill
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Martin Law
- Hub for Trials Methodology Research, Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom; and
| | - Lydia J. Finney
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Luana Alves-Moreira
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Gavin C. Donaldson
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | | | - Jadwiga A. Wedzicha
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Practical Recommendations for a Selection of Inhaled Corticosteroids in COPD: A Composite ICO Chart. Biomolecules 2023; 13:biom13020213. [PMID: 36830583 PMCID: PMC9953425 DOI: 10.3390/biom13020213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/25/2023] Open
Abstract
The use of inhaled corticosteroids (ICS) for the maintenance of bronchodilator treatment in patients with chronic obstructive pulmonary disease (COPD) is controversial. While some patients achieve clinical benefits, such as fewer exacerbations and improved symptoms, others do not, and some experience undesired side effects, such as pneumonia. Thus, we reviewed the evidence related to predictors of ICS therapy treatment response in patients with COPD. The first priority clinical markers when considering the efficacy of ICS are type 2 inflammatory biomarkers, followed by a history of suspected asthma and recurrent exacerbations. It is also necessary to consider any potential infection risk associated with ICS, and several risk factors for pneumonia when using ICS have been clarified in recent years. In this article, based on the evidence supporting the selection of ICS for COPD, we propose an ICS composite that can be added to the COPD (ICO) chart for use in clinical practice. The chart divided the type 2 biomarkers into three ranges and provided recommendations (recommend, consider, and against) by combining the history of suspected asthma, history of exacerbations, and risk of infection.
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Abstract
Eosinophils are important effector cells in airway inflammation, as pleiotropy and heterogeneity can be linked to various pathophysiologies in asthma and chronic obstructive pulmonary disease (COPD). Sputum eosinophils can reflect the heterogeneity of airway inflammation, and owing to their traits, blood eosinophils can be a surrogate and potential biomarker for managing both conditions. Blood eosinophils are activated via the stimulation of type 2 cytokines, such as interleukin (IL)-5, IL-4/13, granulocyte-macrophage colony-stimulating factor, IL-33, and thymic stromal lymphopoietin. There is sufficient evidence to support the relationship between the blood eosinophil count and clinical outcomes, including pulmonary function decline, exacerbations, all-cause mortality, and treatment response to inhaled corticosteroids and biologics. Thus, there is growing interest in the use of blood eosinophils for the management of these diseases. Compiling recent evidence, we herein review the significance of measuring blood eosinophils in asthma and COPD.
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Affiliation(s)
- Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
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5
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Wright A, Vioix H, de Silva S, Langham S, Cook J, Capstick T, Quint JK. Cost-consequence analysis of COPD treatment according to NICE and GOLD recommendations compared with current clinical practice in the UK. BMJ Open 2022; 12:e059158. [PMID: 36691251 PMCID: PMC9171279 DOI: 10.1136/bmjopen-2021-059158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES The objective of this study was to model the clinical and economic impact of adapting current clinical practice in the management of patients with chronic obstructive pulmonary disease (COPD) to treatment according to national and international guideline recommendations. DESIGN Treatment mapping was undertaken to hypothetically redistribute patients from current clinical practice, representing actual prescribing patterns in the UK, to an alternative recommendation-based treatment scenario, representing prescribing in accordance with either National Institute for Health and Care Excellence (NICE) guidance [NG115] or Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 strategy. SETTING Primary care practices in the UK (1-year time horizon). PARTICIPANTS Adults with COPD undergoing long-acting inhaler maintenance therapy in the UK (N=1 067,531). INTERVENTIONS Inhaler maintenance therapy. OUTCOME MEASURES Costs and clinical outcomes (type of treatment, rates of moderate and/or severe exacerbations, and mild-to-moderate and/or severe pneumonia events) were modelled for the two alternative pathways. RESULTS Compared with current clinical practice, treating patients according to NICE guidance resulted in an estimated annual reduction in expenditure of £46.9 million, and an estimated annual reduction in expenditure of over £43.7 million when patients were treated according to GOLD 2020 strategy. Total cost savings of up to 8% annually could be achieved by treatment of patients according to either of these recommendations. Cost savings arose from a reduction in the rates of pneumonia, with an associated decrease in costs associated with antibiotic use and hospitalisation. Savings were achieved overall despite a small increase in the rate of exacerbations due to the redistribution of certain patients currently undergoing triple inhaled therapy to therapies not containing inhaled corticosteroids. CONCLUSION Redistribution of patients with COPD from current clinical practice to treatment according to published recommendations would provide substantial cost savings over the first year.
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Affiliation(s)
| | - Helene Vioix
- Former employees of, Boehringer Ingelheim Ltd, Bracknell, UK
| | | | | | - Jennifer Cook
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
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6
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Love ME, Proud D. Respiratory Viral and Bacterial Exacerbations of COPD—The Role of the Airway Epithelium. Cells 2022; 11:cells11091416. [PMID: 35563722 PMCID: PMC9099594 DOI: 10.3390/cells11091416] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 12/14/2022] Open
Abstract
COPD is a leading cause of death worldwide, with acute exacerbations being a major contributor to disease morbidity and mortality. Indeed, exacerbations are associated with loss of lung function, and exacerbation frequency predicts poor prognosis. Respiratory infections are important triggers of acute exacerbations of COPD. This review examines the role of bacterial and viral infections, along with co-infections, in the pathogenesis of COPD exacerbations. Because the airway epithelium is the initial site of exposure both to cigarette smoke (or other pollutants) and to inhaled pathogens, we will focus on the role of airway epithelial cell responses in regulating the pathophysiology of exacerbations of COPD. This will include an examination of the interactions of cigarette smoke alone, and in combination with viral and bacterial exposures in modulating epithelial function and inflammatory and host defense pathways in the airways during COPD. Finally, we will briefly examine current and potential medication approaches to treat acute exacerbations of COPD triggered by respiratory infections.
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7
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The Use of Inhaled Corticosteroids for Patients with COPD Who Continue to Smoke Cigarettes: An Evaluation of Current Practice. Am J Med 2022; 135:302-312. [PMID: 34655541 DOI: 10.1016/j.amjmed.2021.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022]
Abstract
The use of inhaled corticosteroids (ICS) in combination with inhaled bronchodilators for patients with chronic obstructive pulmonary disease (COPD) is a common practice in primary care settings. However, ICS-containing therapies may be less effective in patients with COPD compared with asthma, and in individuals with COPD who continue to smoke cigarettes. Preclinical studies suggest that inflammation in COPD is very different from in asthma. Glucocorticoid receptor functioning and other innate anti-inflammatory mechanisms are altered in cells exposed to cigarette smoke. COPD may be relatively insensitive to ICS, especially in individuals who continue to smoke. ICS-containing therapies in patients with asthma who continue to smoke may also be less effective compared with patients who do not smoke. ICS-containing therapies may be inappropriately used in some patients with COPD, and their long-term use is associated with an increased risk for side effects, including pneumonia and bone fractures in some patients. Treatment for patients with COPD should be carefully evaluated, and anti-inflammatory/bronchodilatory strategies should be chosen based on individual patient characteristics and recommendations in current guidelines.
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Valipour A, Aisanov Z, Avdeev S, Koblizek V, Kocan I, Kopitovic I, Lupkovics G, Man M, Bukovskis M, Tudoric N, Vukoja M, Naumnik W, Yanev N. Recommendations for COPD management in Central and Eastern Europe. Expert Rev Respir Med 2022; 16:221-234. [PMID: 35001780 DOI: 10.1080/17476348.2021.2023498] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries. AREAS COVERED Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE. EXPERT OPINION Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna Health Care Group, Vienna, Austria
| | - Zaurbek Aisanov
- Department of Pulmonology, Pirogov Russian State National Research Medical University, Moscow, Russia
| | - Sergey Avdeev
- Pulmonology Department, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vladimir Koblizek
- Department of Pneumology, Faculty of Medicine in Hradec Kralove, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Ivan Kocan
- University Hospital Martin, Jessenius Faculty of Medicine, Commenius University, Martin, Slovakia
| | - Ivan Kopitovic
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Gergely Lupkovics
- Adult Pulmonary Department, Institute for Pulmonary Diseases, Törökbálint, Hungary
| | - Milena Man
- Pulmonology Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maris Bukovskis
- Department of Internal Diseases, Faculty Medicine, University of Latvia, Riga, Latvia
| | - Neven Tudoric
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marija Vukoja
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Wojciech Naumnik
- First Department of Lung Diseases and Chemotherapy of Respiratory Neoplasms, Medical University of Bialystok, Bialystok, Poland
| | - Nikolay Yanev
- Department of Pulmonary Diseases, Medical University of Sofia, Sofia, Bulgaria
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Acet‐Öztürk NA, Dilektasli AG, Aydın‐Güçlü Ö, Demirdöğen E, Coşkun F, Ursavaş A, Karadağ M, Uzaslan E. Long‐term oxygen treatment need is less frequent in eosinophilic COPD patients. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:49-56. [PMID: 34626077 PMCID: PMC9060034 DOI: 10.1111/crj.13451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 11/30/2022]
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
| | - Asli G. Dilektasli
- Faculty of Medicine, Department of Pulmonology Uludağ University Bursa Turkey
| | - Özge Aydın‐Güçlü
- Faculty of Medicine, Department of Pulmonology Uludağ University Bursa Turkey
| | - Ezgi Demirdöğen
- Faculty of Medicine, Department of Pulmonology Uludağ University Bursa Turkey
| | - Funda Coşkun
- Faculty of Medicine, Department of Pulmonology Uludağ University Bursa Turkey
| | - Ahmet Ursavaş
- Faculty of Medicine, Department of Pulmonology Uludağ University Bursa Turkey
| | - Mehmet Karadağ
- Faculty of Medicine, Department of Pulmonology Uludağ University Bursa Turkey
| | - Esra Uzaslan
- Faculty of Medicine, Department of Pulmonology Uludağ University Bursa Turkey
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10
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Benson VS, Hartl S, Barnes N, Galwey N, Van Dyke MK, Kwon N. Blood eosinophil counts in the general population and airways disease: a comprehensive review and meta-analysis. Eur Respir J 2022; 59:2004590. [PMID: 34172466 PMCID: PMC8756293 DOI: 10.1183/13993003.04590-2020] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/26/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The clinical context for using blood eosinophil (EOS) counts as treatment-response biomarkers in asthma and COPD requires better understanding of EOS distributions and ranges. We describe EOS distributions and ranges published in asthma, COPD, control (non-asthma/COPD) and general populations. METHODS We conducted a comprehensive literature review and meta-analysis of observational studies (January 2008 to November 2018) that included EOS counts in asthma, severe asthma, COPD, control and general populations. Excluded studies had total sample sizes <200, EOS as inclusion criterion, hospitalised population only and exclusively paediatric participants. RESULTS Overall, 91 eligible studies were identified, most had total-population-level data available: asthma (39 studies), severe asthma (12 studies), COPD (23 studies), control (seven studies) and general populations (14 studies); some articles reported data for multiple populations. Reported EOS distributions were right-skewed (seven studies). Reported median EOS counts ranged from 157-280 cells·µL-1 (asthma, 22 studies); 200-400 cells·µL-1 (severe asthma, eight studies); 150-183 cells·µL-1 (COPD, six studies); and 100-160 cells·µL-1 (controls, three studies); and 100-200 cells·µL-1 (general populations, six studies). The meta-analysis showed that observed variability was mostly between studies rather than within studies. Factors reportedly associated with higher blood EOS counts included current smoking, positive skin-prick test, elevated total IgE, comorbid allergic rhinitis, age ≤18 years, male sex, spirometric asthma/COPD diagnosis, metabolic syndrome and adiposity. CONCLUSION EOS distribution and range varied by study population, and were affected by clinical factors including age, smoking history and comorbidities, which, regardless of severity, should be considered during treatment decision-making.
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Affiliation(s)
- Victoria S Benson
- Epidemiology, Value Evidence and Outcomes (VEO), Global Medical R&D, GlaxoSmithKline, Brentford, UK
| | - Sylvia Hartl
- Dept of Respiratory and Critical Care Medicine and Ludwig Boltzmann Institute for Lung Health, Clinic Penzing, WiGev and Sigmund Freud University, Medical School, Vienna, Austria
| | - Neil Barnes
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, UK
- William Harvey Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Melissa K Van Dyke
- Epidemiology, Value Evidence and Outcomes (VEO), Global Medical R&D, GlaxoSmithKline, Upper Providence, PA, USA
| | - Namhee Kwon
- Respiratory Research and Development, GlaxoSmithKline, Brentford, UK
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11
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Treatment Response Biomarkers in Asthma and COPD. Diagnostics (Basel) 2021; 11:diagnostics11091668. [PMID: 34574009 PMCID: PMC8464838 DOI: 10.3390/diagnostics11091668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) and asthma are two of the most common chronic diseases worldwide. Both diseases are heterogenous and complex, and despite their similarities, they differ in terms of pathophysiological and immunological mechanisms. Mounting evidence supports the presence of several phenotypes with various responses to treatment. A systematic and thorough assessment concerning the diagnosis of both asthma and COPD is crucial to the clinical management of the disease. The identification of different biomarkers can facilitate targeted treatment and monitoring. Thanks to the presence of numerous immunological studies, our understanding of asthma phenotypes and mechanisms of disease has increased markedly in the last decade, and several treatments with monoclonal antibodies are available. There are compelling data that link eosinophilia with an increased risk of COPD exacerbations but a greater treatment response and lower all-cause mortality. Eosinophilia can be considered as a treatable trait, and the initiation of inhaled corticosteroid in COPD patients with eosinophilia is supported in many studies. In spite of advances in our understanding of both asthma and COPD in terms pathophysiology, disease mechanisms, biomarkers, and response to treatment, many uncertainties in the management of obstructive airways exist.
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López-Campos JL, Carrasco Hernández L, Ruiz-Duque B, Reinoso-Arija R, Caballero-Eraso C. Step-Up and Step-Down Treatment Approaches for COPD: A Holistic View of Progressive Therapies. Int J Chron Obstruct Pulmon Dis 2021; 16:2065-2076. [PMID: 34285480 PMCID: PMC8285922 DOI: 10.2147/copd.s275943] [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: 03/20/2021] [Accepted: 06/19/2021] [Indexed: 11/30/2022] Open
Abstract
Recent advances in inhaled drugs and a clearer definition of the disease have made the task of managing COPD more complex. Different proposals have been put forward which combine all the available treatments and the different clinical presentations in an effort to select the best therapeutic options for each clinical context. As COPD is a chronic progressive disease, the escalation of therapy has traditionally been considered the most natural way to tackle it. However, the notion of COPD as a constantly progressing disease has recently been challenged and, in specific areas, this points to the possibility of a de-escalation in treatment. In this context, the clinician requires simple, specific recommendations to guide these changes in treatment in their daily clinical practice. To accomplish this, the first step must be a correct evaluation and an accurate initial preliminary diagnosis of the patient's condition. Thereafter, the first escalation in therapy must be introduced with caution as the disease progresses, since clinical trials are not designed with clinical decision-making in mind. During this escalation, three possibilities are open to change the current treatment for a different one within the same family, to increase non-pharmacological interventions or to increase the pharmacological therapies. Beyond that point, a patient with persistent symptoms represents a complex clinical scenario which requires a specialized approach, including the evaluation of different respiratory and non-respiratory comorbidities. Unfortunately, there are few de-escalation studies available, and these are mainly observational in nature. The debate on de-escalation in pharmacological treatment, therefore, involves two main discussion points: the withdrawal of bronchodilators and the withdrawal of inhaled steroids. Altogether, the scheme for modifying treatment must be more personalized than just adding molecules, and the therapeutic response and its conditioning factors should be evaluated at each step before proceeding further.
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Affiliation(s)
- Jose Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Carrasco Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Borja Ruiz-Duque
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
| | - Rocio Reinoso-Arija
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
| | - Candelaria Caballero-Eraso
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Muro S, Suzuki M, Nakamura S, Wang JR, Garry EM, Sakamoto W, de Souza S. Real-world effectiveness of early intervention with fixed-dose tiotropium/olodaterol vs tiotropium in Japanese patients with COPD: a high-dimensional propensity score-matched cohort analysis. Respir Res 2021; 22:180. [PMID: 34140019 PMCID: PMC8212527 DOI: 10.1186/s12931-021-01776-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background Escalation to triple therapy (long-acting muscarinic antagonist/β2-agonist, inhaled corticosteroid [ICS]) in chronic obstructive pulmonary disorder (COPD) is recommended for patients on LAMA/LABA combinations with frequent exacerbations and severe symptoms. An extended time-to-escalation to triple therapy suggests patients are in a stable condition and is an indicator of treatment effectiveness. No studies in Japanese clinical practice have compared the effectiveness of LAMA/LABA fixed-dose combination therapies with LAMA monotherapy in terms of time-to-escalation to triple therapy. The primary objective of this real-world study in Japan was to compare time-to-escalation to triple therapy among new users of tiotropium/olodaterol or tiotropium monotherapy for COPD without asthma. Methods In this active-comparator cohort study, new users of tiotropium/olodaterol (n = 1436) and tiotropium monotherapy (n = 5352) were identified from a large Japanese hospital-based database (Medical Data Vision Co., Ltd., Tokyo; prespecified study period: 1 April 2015 to 31 March 2019); patients in each group were matched 1:1 using high-dimensional propensity scores (hdPS). The primary outcome was time-to-escalation to triple therapy. Results For the prespecified study period in the hdPS-matched cohort, escalation to triple therapy was infrequent among new users of tiotropium/olodaterol (n = 1302, 7 escalation events) and tiotropium monotherapy (n = 1302, 8 escalation events). The difference in time-to-escalation to triple therapy between groups was not statistically significant (median [interquartile range]: 28 days [15.0–139.2] for tiotropium monotherapy vs 193 days [94.5–302.0] for tiotropium/olodaterol; hazard ratio: 0.89; 95% CI: 0.32–2.46). Similar findings (hazard ratio: 0.71; 95% Cl: 0.36–1.40) were observed in a post hoc analysis, which extended the study period by 1 year to 31 March 2020. Risks of first moderate and/or severe COPD exacerbation were lower for tiotropium/olodaterol than tiotropium monotherapy (between-group differences not significant). There were no significant between-group differences for the risks of all-cause inpatient mortality, major adverse cardiovascular events, and first use of home oxygen therapy. Conclusions ICS monotherapy or ICS/LABA added to tiotropium or tiotropium/olodaterol is limited in Japanese clinical settings. The number of escalations to triple therapy was very limited in the dataset and there was insufficient power to detect differences between the treatment groups in the primary hdPS-matched cohort. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01776-y.
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Affiliation(s)
- Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, 840, Shijo-cho, Kashihara-shi, Nara, 634-8522, Japan.
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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14
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Abstract
Pharmacological treatment for chronic obstructive pulmonary disease (COPD) aims to alleviate symptoms and reduce the future risk of events such as exacerbations, disease progression and death. The heterogeneity of COPD results in variable responses to pharmacological interventions. COPD treatment has evolved towards a precision medicine approach, integrating clinical and biomarker information in order to optimize treatment decisions for each individual. The evidence supporting the use of blood eosinophil counts to predict responses to inhaled corticosteroids (ICS) in COPD patients has led to the adoption of this biomarker for use in clinical practice. The development of novel double and triple inhaled combination treatments containing long-acting bronchodilators with or without ICS has involved some landmark randomized controlled trials in COPD patients. These studies have provided valuable evidence to direct the use of different classes of combination treatments. However, there are still some unresolved questions and debates. This review article describes the advances in the pharmacological treatment of COPD, particularly the personalization of treatment. The evidence base for current recommendations is discussed, and controversial issues are dissected.
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Affiliation(s)
- Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Hospital Trust, Manchester, UK
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15
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Calverley P. Reigniting the TORCH: Chronic Obstructive Pulmonary Disease Mortality and Inhaled Corticosteroids Revisited. Am J Respir Crit Care Med 2021; 203:531-532. [PMID: 33326362 PMCID: PMC7924572 DOI: 10.1164/rccm.202012-4300ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Peter Calverley
- Institute of Ageing and Chronic Disease University of Liverpool Liverpool, United Kingdom
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16
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Sivapalan P, Bikov A, Jensen JU. Using Blood Eosinophil Count as a Biomarker to Guide Corticosteroid Treatment for Chronic Obstructive Pulmonary Disease. Diagnostics (Basel) 2021; 11:236. [PMID: 33546498 PMCID: PMC7913607 DOI: 10.3390/diagnostics11020236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 02/07/2023] Open
Abstract
Treating patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (COPD) usually involves administering systemic corticosteroids. The many unwanted side effects associated with this treatment have led to increased interest in minimising the accumulated corticosteroid dose necessary to treat exacerbations. Studies have shown that short-term treatment with corticosteroids is preferred, and recent trials have shown that biomarkers can be used to further reduce exposure to corticosteroids. Interestingly, high eosinophil counts in patients with acute exacerbations of COPD are indicative of an eosinophilic phenotype with a distinct response to treatment with corticosteroids. In addition, post-hoc analysis of randomised control trials have shown that higher blood eosinophil counts at the start of the study predict a greater response to inhaled corticosteroids in stable COPD. In this review, we examine the studies on this topic, describe how blood eosinophil cell count may be used as a biomarker to guide treatment with corticosteroids, and identify some relevant challenges.
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Affiliation(s)
- Pradeesh Sivapalan
- Department of Internal Medicine, Respiratory Medicine Section, Herlev-Gentofte Hospital, 2900 Hellerup, Denmark;
- Department of Internal Medicine, Zealand University Hospital, 4000 Roskilde, Denmark
| | - András Bikov
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK;
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester M13 9NT, UK
| | - Jens-Ulrik Jensen
- Department of Internal Medicine, Respiratory Medicine Section, Herlev-Gentofte Hospital, 2900 Hellerup, Denmark;
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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17
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Ferguson GT, Shaikh A, Tetzlaff K, Mueller A, Magnussen H, Watz H. Effect of Inhaled Corticosteroid Withdrawal on Chronic Obstructive Pulmonary Disease Exacerbations in Patients Taking Triple Therapy at Baseline. Int J Chron Obstruct Pulmon Dis 2020; 15:2879-2888. [PMID: 33204084 PMCID: PMC7667507 DOI: 10.2147/copd.s237408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 09/23/2020] [Indexed: 02/03/2023] Open
Abstract
Purpose In the Withdrawal of Inhaled Steroids during Optimized Bronchodilator Management (WISDOM) trial, inhaled corticosteroid (ICS) withdrawal in patients with chronic obstructive pulmonary disease receiving triple therapy (long-acting β2-agonist+long-acting muscarinic antagonist+ICS) did not change moderate/severe exacerbation risk. However, many patients were not taking triple therapy before study participation. This analysis was conducted to eliminate the impact of non-ICS users on WISDOM results by re-analyzing the data using only the subset of patients who were taking triple therapy at screening. Patients and Methods The effect of ICS withdrawal on moderate/severe exacerbation risk in the subgroup of WISDOM patients taking triple therapy before enrolling in the study was evaluated in this post hoc analysis. Additionally, the effect of ICS withdrawal in patients with a history of ≥2 exacerbations in the previous year and various blood eosinophil counts was assessed. Results Overall, 39.0% (n=970: ICS continuation, 479; ICS withdrawal, 491) of the WISDOM trial population were taking triple therapy at screening. Baseline characteristics were generally similar between groups. Moderate/severe exacerbation risk between the ICS withdrawal and continuation groups (hazard ratio [HR], 1.05; 95% confidence interval [CI]: 0.89–1.25) was not increased in patients taking triple therapy at screening versus the overall trial population (HR [95% CI]: 1.06 [0.94–1.19]). However, in patients with a history of ≥2 exacerbations, exacerbation risk (HR [95% CI]) increased nominally with blood eosinophil count from 1.07 [0.81–1.41] (≥100 cells/μL) to 1.45 [0.58–3.60] (≥400 cells/μL). Conclusion Consistent with results from the overall WISDOM trial population, ICS withdrawal did not increase exacerbation risk in patients taking triple therapy at screening. Patients with a history of frequent exacerbations and higher blood eosinophil counts could benefit from continuation of ICS-based therapy. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/q_gF6ypMYJw
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Affiliation(s)
- Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Kay Tetzlaff
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Achim Mueller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Henrik Watz
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
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18
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Calverley P. Angels Dancing on the Tip of a Needle: Interpreting Clinical Trials in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2020; 202:1206-1207. [PMID: 32758103 PMCID: PMC7605183 DOI: 10.1164/rccm.202007-2863ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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19
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The Role of Electronic Noses in Phenotyping Patients with Chronic Obstructive Pulmonary Disease. BIOSENSORS-BASEL 2020; 10:bios10110171. [PMID: 33187142 PMCID: PMC7697924 DOI: 10.3390/bios10110171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common progressive disorder of the respiratory system which is currently the third leading cause of death worldwide. Exhaled breath analysis is a non-invasive method to study lung diseases, and electronic noses have been extensively used in breath research. Studies with electronic noses have proved that the pattern of exhaled volatile organic compounds is different in COPD. More recent investigations have reported that electronic noses could potentially distinguish different endotypes (i.e., neutrophilic vs. eosinophilic) and are able to detect microorganisms in the airways responsible for exacerbations. This article will review the published literature on electronic noses and COPD and help in identifying methodological, physiological, and disease-related factors which could affect the results.
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20
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Papaioannou AI, Loukides S, Bakakos P, Kosmas EN, Rovina N, Steiropoulos P, Fouka E, Hillas G, Patentalakis G, Kouvela M, Tzanakis N. Dual Bronchodilator in the Era of Triple Therapy. Int J Chron Obstruct Pulmon Dis 2020; 15:2695-2705. [PMID: 33149567 PMCID: PMC7604249 DOI: 10.2147/copd.s273987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/23/2020] [Indexed: 01/18/2023] Open
Abstract
Pharmacological medications used for the treatment of COPD patients have increased significantly. Long-acting bronchodilators have been recognized as the mainstay of the treatment of stable COPD, while ICS are usually added in patients with COPD who experience exacerbations, despite bronchodilator treatment. In the latest years, several studies have been published showing the beneficial effect of adding ICS on dual bronchodilation in patients suffering from more severe disease comparing triple therapy with several therapeutic regiments including dual bronchodilation and providing a message that this triple therapy might be more appropriate for COPD patients. However, not all COPD patients have a desirable response to ICS treatment while long-term ICS use in COPD is associated with several side effects. In this report, we aimed to provide a review of the current knowledge on the importance of dual bronchodilation on COPD patients and to compare its use with triple therapy, by covering a wide spectrum of topics. Finally, we propose an algorithm on performing treatment step up from dual bronchodilation to triple therapy and step down from triple to double bronchodilation considering the current evidence.
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Affiliation(s)
- Andriana I Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Petros Bakakos
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | | | - Nikoletta Rovina
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangellia Fouka
- Respiratory Medicine Department, Aristotle University of Thessaloniki, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Georgios Hillas
- 5th Respiratory Medicine Department, Sotiria Chest Hospital, Athens, Greece
| | | | - Marousa Kouvela
- 3rd Department of Medicine, Athens Medical School, Athens, Greece
| | - Nikos Tzanakis
- Department of Thoracic Medicine, Faculty of Medicine, University of Crete, Crete, Greece
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21
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van Dijk M, Gan CT, Koster TD, Wijkstra PJ, Slebos DJ, Kerstjens HAM, van der Vaart H, Duiverman ML. Treatment of severe stable COPD: the multidimensional approach of treatable traits. ERJ Open Res 2020; 6:00322-2019. [PMID: 32984420 PMCID: PMC7502698 DOI: 10.1183/23120541.00322-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/26/2020] [Indexed: 01/02/2023] Open
Abstract
Now that additional treatment options for severe chronic obstructive pulmonary disease (COPD) have emerged in recent years, patients with severe COPD should not be left in the rather hopeless situation of “there is nothing to improve” any more. Inertia or fatalism is a disservice to our patients. Ranging from advanced care planning to quite intense and demanding therapies such as multidisciplinary pulmonary rehabilitation, (endoscopic) lung volume reduction, chronic noninvasive ventilation and lung transplantation, caregivers should try to provide a personalised treatment for every severe COPD patient. In this review, we aim to describe the multidimensional approach to these patients at our centre along the lines of treatable traits leading to specific additional treatment modalities on top of standard care. Severe COPD is not hopeless; in light of treatment options such as pulmonary rehabilitation, bronchoscopic lung volume reduction, chronic noninvasive ventilation and lung transplantation, every patient deserves a personalised assessment of treatable traitshttps://bit.ly/2TO7jxB
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Affiliation(s)
- Marlies van Dijk
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Christiaan T Gan
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - T David Koster
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Peter J Wijkstra
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Hester van der Vaart
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands.,Centre of Rehabilitation Beatrixoord, Haren, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marieke L Duiverman
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
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22
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Singh D, Wedzicha JA, Siddiqui S, de la Hoz A, Xue W, Magnussen H, Miravitlles M, Chalmers JD, Calverley PMA. Blood eosinophils as a biomarker of future COPD exacerbation risk: pooled data from 11 clinical trials. Respir Res 2020; 21:240. [PMID: 32943047 PMCID: PMC7499955 DOI: 10.1186/s12931-020-01482-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/06/2020] [Indexed: 12/23/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow limitation and chronic inflammation. Predicting exacerbations of COPD, which contribute to disease progression, is important to guide preventative treatment and improve outcomes. Blood eosinophils are a biomarker for patient responsiveness to inhaled corticosteroids (ICS); however, their effectiveness as a predictive biomarker for COPD exacerbations is unclear. Methods This post hoc analysis pooled data from 11 Boehringer Ingelheim-sponsored Phase III and IV randomised COPD studies with similar methodologies. Exacerbation data were collected from these studies, excluding patients from the ICS withdrawal arm of the WISDOM® study. Patients were grouped according to their baseline blood eosinophil count, baseline ICS use and number of exacerbations in the year prior to each study. Results Exacerbation rate data and baseline eosinophil count were available for 22,125 patients; 45.6% presented with a baseline blood eosinophil count of ≤ 150 cells/μL, 34.3% with 150–300 cells/μL and 20.1% with > 300 cells/μL. The lowest exacerbation rates were observed in patients with ≤ 150 cells/μL, with small increases in exacerbation rate observed with increasing eosinophil count. When stratified by exacerbation history, the annual rate of exacerbations for patients with 0 exacerbations in the previous year increased in line with increasing eosinophil counts (0.38 for ≤ 150 cells/μL, 0.39 for 150–300 cells/μL and 0.44 for > 300 cells/μL respectively). A similar trend was identified for patients with one exacerbation in the previous year, 0.62, 0.66 and 0.67 respectively. For patients with ≥ 2 exacerbations, exacerbation rates fluctuated between 1.02 (≤ 150 cells/μL) to 1.10 (150–300 cells/μL) and 1.07 (> 300 cells/μL). Higher exacerbation rates were noted in patients treated with ICS at baseline (range 0.75 to 0.82 with increasing eosinophil count) compared with patients not on ICS (range 0.45 to 0.49). Conclusion We found no clinically important relationship between baseline blood eosinophil count and exacerbation rate. Hence, the current analysis does not support the use of blood eosinophils to predict exacerbation risk; however, previous exacerbation history was found to be a more reliable predictor of future exacerbations. Trial registration ClinicalTrials.gov Identifiers: NCT00168844, NCT00168831, NCT00387088, NCT00782210, NCT00782509, NCT00793624, NCT00796653, NCT01431274, NCT01431287, NCT02296138 and NCT00975195. Graphical abstract ![]()
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Jadwiga A Wedzicha
- Respiratory Division, National Heart and Lung Institute, Imperial College London, London, UK
| | - Salman Siddiqui
- NIHR Leicester Biomedical Research Centre: Respiratory Theme, and Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wenqiong Xue
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Grosshansdorf, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Peter M A Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
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23
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Oshagbemi OA, Odiba JO, Daniel A, Yunusa I. Absolute Blood Eosinophil Counts to Guide Inhaled Corticosteroids Therapy Among Patients with COPD: Systematic Review and Meta-analysis. Curr Drug Targets 2020; 20:1670-1679. [PMID: 31393244 DOI: 10.2174/1389450120666190808141625] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/16/2019] [Accepted: 07/22/2019] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019 recommends the use of absolute blood eosinophil count as a guide for the escalation and de-escalation of inhaled corticosteroids (ICS) in the pharmacological management of patients with chronic obstructive pulmonary disease (COPD). We evaluated the risk of moderate or severe exacerbations among patients escalating and de-escalating ICS therapy by absolute blood eosinophil thresholds in this systematic review. METHODS Through a comprehensive literature search of Pubmed/MEDLINE, EMBASE, and clinical trial sites up to April 2019, we identified relevant studies. We used generic inverse variance method with fixed-effects estimates to compare the risk of moderate or severe exacerbations among COPD patients with elevated blood eosinophil counts exposed to inhaled corticosteroids (ICS) versus non-ICS treatments groups expressed as risk ratios. RESULTS Ten studies (8 randomised control trials and 2 observational studies) were included, with a total of 85,059 COPD patients. In our pooled analysis, we found an overall reduction in risk of moderate or severe exacerbations in patients with absolute blood eosinophil thresholds ranging from ≥ 100 to ≥ 340 cells/µL among patients escalating ICS (RR, 0.77, 95% CI, 0.73-0.81). For studies evaluating the effects of de-escalation of ICS on moderate to severe exacerbations using blood eosinophil thresholds of ≥ 300 to ≥ 340 cells/µL had an increased risk of moderate or severe exacerbations following the de-escalation of ICS (RR, 1.66, 95% CI, 1.31-2.10). CONCLUSION This study confirms the validity of the recommended absolute blood eosinophil count thresholds for the escalation and de-escalation of ICS among COPD patients. However, this recommendation is for COPD patients with prior exacerbations rather than among newly diagnosed COPD patients as observed in this study. COPD patients with current or past history of asthma represent a unique phenotypic group which should be further evaluated.
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Affiliation(s)
- Olorunfemi A Oshagbemi
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Netherlands
| | - Jephthah O Odiba
- Monash Institute of Pharmaceutical Sciences, Melbourne, Australia
| | | | - Ismaeel Yunusa
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
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Singh D, Bafadhel M, Brightling CE, Sciurba FC, Curtis JL, Martinez FJ, Pasquale CB, Merrill DD, Metzdorf N, Petruzzelli S, Tal-Singer R, Compton C, Rennard S. Blood Eosinophil Counts in Clinical Trials for Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2020; 202:660-671. [PMID: 32186896 PMCID: PMC7462391 DOI: 10.1164/rccm.201912-2384pp] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/17/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Dave Singh
- Division of Infection, Immunity, and Respiratory Medicine, University of Manchester, Manchester University National Health Service Hospital Trust, Manchester, United Kingdom
| | - Mona Bafadhel
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Christopher E. Brightling
- Institute for Lung Health, National Institute for Health Research Leicester Biomedical Research Centre, Department of Respiratory and Infection Sciences, University of Leicester, Leicester, United Kingdom
| | - Frank C. Sciurba
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeffrey L. Curtis
- Pulmonary and Critical Care Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Fernando J. Martinez
- Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, New York
| | - Cara B. Pasquale
- COPD Patient-Powered Research Network, COPD Foundation, Washington, DC
| | - Debora D. Merrill
- COPD Biomarkers Qualification Consortium, COPD Foundation, Miami, Florida
| | - Norbert Metzdorf
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Ruth Tal-Singer
- COPD Biomarkers Qualification Consortium, COPD Foundation, Miami, Florida
| | - Christopher Compton
- Global Medical Affairs, Speciality and Primary Care, GlaxoSmithKline, Middlesex, United Kingdom
| | - Stephen Rennard
- Biopharmaceuticals R&D, AstraZeneca, Cambridge, United Kingdom
- University of Nebraska Medical Center, Omaha, Nebraska; and
| | - on behalf of the COPD Foundation Eosinophil Working Group
- Division of Infection, Immunity, and Respiratory Medicine, University of Manchester, Manchester University National Health Service Hospital Trust, Manchester, United Kingdom
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Institute for Lung Health, National Institute for Health Research Leicester Biomedical Research Centre, Department of Respiratory and Infection Sciences, University of Leicester, Leicester, United Kingdom
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Pulmonary and Critical Care Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
- Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, New York
- COPD Patient-Powered Research Network, COPD Foundation, Washington, DC
- COPD Biomarkers Qualification Consortium, COPD Foundation, Miami, Florida
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
- Global Medical Affairs, Speciality and Primary Care, GlaxoSmithKline, Middlesex, United Kingdom
- Biopharmaceuticals R&D, AstraZeneca, Cambridge, United Kingdom
- University of Nebraska Medical Center, Omaha, Nebraska; and
- Research and Development, AstraZeneca, Gaithersburg, Maryland
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25
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Mycroft K, Krenke R, Górska K. Eosinophils in COPD-Current Concepts and Clinical Implications. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:2565-2574. [PMID: 32251737 DOI: 10.1016/j.jaip.2020.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/03/2020] [Accepted: 03/08/2020] [Indexed: 01/20/2023]
Abstract
In recent years, heterogeneity in chronic obstructive pulmonary disease (COPD) inflammatory patterns has been recognized as a basis for more precise treatment interventions because current therapies have limited effectiveness. Eosinophilic airway inflammation in COPD has become a subject of research interest as a potential treatment target for inhaled corticosteroid therapy. However, the role of eosinophils in COPD is still unclear, and it is unknown why only some patients with COPD develop eosinophilic airway inflammation. Induced sputum analysis is the most common method of assessing the type of airway inflammation. Accessibility to sputum induction, however, is limited in clinical practice, and blood eosinophils have been proposed to serve as a surrogate marker and treatment guide. Blood eosinophil count has been shown to poorly predict sputum eosinophilia, and, moreover, it seems to be fairly unstable and affected by various factors. Nevertheless, in several trials, blood eosinophil count appeared to predict good response to inhaled corticosteroids However, biologics targeting eosinophils do not appear to be effective in COPD. In this review, we briefly summarize the current knowledge on eosinophils in COPD pathogenesis. Then, we discuss the use of blood eosinophil count in COPD in relation to the recent Global Initiative for Chronic Obstructive Pulmonary Disease recommendations, their ability to predict sputum eosinophilia, and their potential role in guiding treatment.
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Affiliation(s)
- Katarzyna Mycroft
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Górska
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland.
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26
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Lam JCM. Switching from long‐acting beta‐agonist and inhaled corticosteroid to long‐acting beta‐agonist and long‐acting muscarinic antagonist for chronic obstructive pulmonary disease: a case report of inhaled corticosteroid withdrawal. Intern Med J 2020; 50 Suppl 3:15-18. [DOI: 10.1111/imj.14931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jamie Chung Mei Lam
- Respiratory Medicine Centre Hong Kong Sanatorium and Hospital Hong Kong
- Department of Medicine The University of Hong Kong Hong Kong
- Department of Medicine and Therapeutics The Chinese University of Hong Kong Hong Kong
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27
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Yoon JK, Lee JK, Lee CH, Hwang YI, Kim H, Park D, Hwang KE, Kim SH, Jung KS, Yoo KH, Ra SW, Kim DK. The Association Between Eosinophil Variability Patterns and the Efficacy of Inhaled Corticosteroids in Stable COPD Patients. Int J Chron Obstruct Pulmon Dis 2020; 15:2061-2070. [PMID: 32943859 PMCID: PMC7473991 DOI: 10.2147/copd.s258353] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/09/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Blood eosinophils are a predictive marker for the use of inhaled corticosteroids (ICS). However, there is concern over whether a single measure of blood eosinophils is sufficient for outlining a treatment plan. Here, we evaluated the association between variability in blood eosinophils and the effects of ICS in stable COPD cohorts. Methods COPD patients in the Korean COPD Subtype Study and the Seoul National University Airway Registry from 2011 to 2018 were analyzed. Based on blood eosinophils at baseline and at 1-year follow-up, the patients were classified into four groups with 250/μL as a cutoff value: consistently high (CH), consistently low (CL), variably increasing (VI), and variably decreasing (VD). We compared rates of acute exacerbations (AEs) according to ICS use in each group after calibration of severity using propensity score matching. Results Of 2,221 COPD patients, 618 were analyzed and a total of 125 (20%), 355 (57%), 63 (10%), and 75 (12%) patients were classified into the CH, CL, VI, and VD groups, respectively. After calibration, we found that ICS users tended to have a lower AE rate in the CH group (RR 0.41, 95% CI 0.21–0.74) and VI group (RR 0.45, 95% CI 0.22–0.88), but not in the CL group (RR 1.42, 95% CI 1.08–1.89) and VD group (RR 1.71, 95% CI 1.00–2.96). Conclusion More than one-fifth of patients had an inconsistent blood eosinophil level after the 1-year follow-up, and the AE-COPD rate according to ICS differed based on variability in eosinophils. Regular follow-up of blood eosinophils is required for COPD patients.
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Affiliation(s)
- Jung-Ki Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Il Hwang
- Department of Internal Medicine, College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyunkuk Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Dongil Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Ki-Eun Hwang
- Department of Internal Medicine, Wonkwang University, School of Medicine, Iksan, Republic of Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Ki-Suck Jung
- Department of Internal Medicine, College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kwang Ha Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seung Won Ra
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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28
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Martinez-Garcia MA, Posadas T, Sotgiu G, Blasi F, Saderi L, Aliberti S. Role of inhaled corticosteroids in reducing exacerbations in bronchiectasis patients with blood eosinophilia pooled post-hoc analysis of 2 randomized clinical trials. Respir Med 2020; 172:106127. [PMID: 32905889 DOI: 10.1016/j.rmed.2020.106127] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 11/15/2022]
Affiliation(s)
| | - Tomás Posadas
- Pneumology Department, Hospital Universitario i Politécnico La Fe, Valencia, Spain
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Francesco Blasi
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy.
| | - Stefano Aliberti
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
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29
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Lopez-Campos JL, Ruiz-Duque B, Carrasco-Hernandez L, Caballero-Eraso C. Integrating Comorbidities and Phenotype-Based Medicine in Patient-Centered Medicine in COPD. J Clin Med 2020; 9:jcm9092745. [PMID: 32854364 PMCID: PMC7565552 DOI: 10.3390/jcm9092745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
Despite recent notable innovations in the management of chronic obstructive pulmonary disease (COPD), no major advances in patient-centered medicine have been achieved. Current guidelines base their proposals on the average results from clinical trials, leading to what could be termed ‘means-based’ medical practice. However, the therapeutic response is variable at the patient level. Additionally, the variability of the clinical presentation interacts with comorbidities to form a complex clinical scenario for clinicians to deal with. Consequently, no consensus has been reached over a practical approach for combining comorbidities and disease presentation markers in the therapeutic algorithm. In this context, from the patients’ first visit, the clinician faces four major dilemmas: (1) establishing the correct diagnosis of COPD as opposed to other airway diseases, such as bronchial asthma; (2) deciding on the initial therapeutic approach based on the clinical characteristics of each case; (3) setting up a study strategy for non-responding patients; (4) pursuing a follow-up strategy with two well-defined periods according to whether close or long-term follow-up is required. Here, we will address these major dilemmas in the search for a patient-centered approach to COPD management and suggest how to combine them all in a single easy-to-use strategy.
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Affiliation(s)
- José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, 41013 Sevilla, Spain; (B.R.-D.); (L.C.-H.); (C.C.-E.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence:
| | - Borja Ruiz-Duque
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, 41013 Sevilla, Spain; (B.R.-D.); (L.C.-H.); (C.C.-E.)
| | - Laura Carrasco-Hernandez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, 41013 Sevilla, Spain; (B.R.-D.); (L.C.-H.); (C.C.-E.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Candelaria Caballero-Eraso
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, 41013 Sevilla, Spain; (B.R.-D.); (L.C.-H.); (C.C.-E.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a heterogeneous syndrome and may comprise several different phenotypes that are driven by different molecular mechanisms (endotypes). Several different clinical, genetic, and inflammatory phenotypes of COPD have been recognized and this may lead to more precise effective therapies. AREAS COVERED The different clinical phenotypes, including smoking versus nonsmoking COPD, small airway disease versus emphysema, non-exacerbators versus frequent exacerbators are discussed. Rare genetic endotypes (alpha1-antitrypsin deficiency, telomerase polymorphisms), and inflammatory phenotypes (eosinophilic versus neutrophilic) are also recognized in stable and exacerbating patients and have implications for the choice of therapy. EXPERT OPINION Clinical phenotypes have so far not proved to be very useful in selecting more personalized therapy for COPD. Even with genetic endotypes, this has not led to improved therapy. More promising is the recognition that COPD patients who have increased sputum or blood eosinophils tend to have more frequent exacerbations and inhaled corticosteroids are more effective in preventing exacerbation. Increased blood eosinophils have proved to be a useful biomarker now used to target ICS more effectively. Furthermore, COPD patients with low eosinophils are more likely to get pneumonia with ICS and to have lower airway bacterial colonization.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College London , London, UK
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31
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Halpin DMG, Dransfield MT, Han MK, Jones CE, Kilbride S, Lange P, Lipson DA, Lomas DA, Martinez FJ, Pascoe S, Singh D, Wise R, Criner GJ. The effect of exacerbation history on outcomes in the IMPACT trial. Eur Respir J 2020; 55:13993003.01921-2019. [PMID: 32299860 PMCID: PMC7286387 DOI: 10.1183/13993003.01921-2019] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/17/2020] [Indexed: 12/18/2022]
Abstract
IMPACT, a 52-week, randomised, double-blind trial, assessed the efficacy and safety of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) triple therapy versus FF/VI or UMEC/VI in patients with symptomatic COPD and a history of exacerbations. Subgroup analyses assessed whether the efficacy of FF/UMEC/VI versus FF/VI or UMEC/VI and UMEC/VI versus FF/VI varies according to prior exacerbation history, and the combined effects of exacerbation history and blood eosinophil counts. Three subgroups were defined: single moderate (1 moderate/no severe; n=3056 (30%)), frequent moderate (≥2 moderate/no severe; n=4628 (45%)) and severe (≥1 severe/any moderate; n=2671 (26%)). End-points included annual on-treatment moderate/severe exacerbation rate (pre-specified), lung function and health status (both post-hoc). Moderate/severe exacerbation rates (reduction % (95% CI)) were reduced in the FF/UMEC/VI group versus FF/VI (single moderate 20% (10–29), frequent moderate 11% (2–19), severe 17% (7–26)) and versus UMEC/VI (single moderate 18% (5–29), frequent moderate 29% (21–37), severe 26% (14–35)). Moderate/severe exacerbation rates were reduced in the FF/VI group versus UMEC/VI in the frequent moderate subgroup; a numerical reduction was observed in the severe subgroup (single moderate 2% (−12–18), frequent moderate 21% (11–29), severe 11% (−3–22)). Moderate/severe exacerbation rates were lower in the FF/VI group compared with UMEC/VI in patients with higher eosinophil counts. FF/UMEC/VI improved lung function and health status versus both dual therapies irrespective of exacerbation subgroup. UMEC/VI improved lung function versus FF/VI in all subgroups. Triple therapy was more effective than dual regardless of exacerbation history, consistent with results in the intent-to-treat population. Comparisons between dual therapies were influenced by prior exacerbation history and eosinophil counts. FF/UMEC/VI shows benefits vs FF/VI and UMEC/VI across multiple endpoints irrespective of exacerbation history. Exacerbation history and eosinophils influenced the comparison between UMEC/VI and FF/VI, and eosinophils that between FF/UMEC/VI and UMEC/VI.http://bit.ly/2SHu2ey
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Affiliation(s)
- David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - MeiLan K Han
- University of Michigan, Pulmonary & Critical Care, Ann Arbor, MI, USA
| | | | | | - Peter Lange
- Medical Dept, Herlev and Gentofte Hospital, Herlev, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | - David A Lipson
- GlaxoSmithKline, Collegeville, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Lomas
- UCL Respiratory, University College London, London, UK
| | - Fernando J Martinez
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Steve Pascoe
- GlaxoSmithKline, Collegeville, PA, USA.,Sanofi, Philadelphia, PA, USA
| | - Dave Singh
- University of Manchester, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Hospitals Trust, Manchester, UK
| | - Robert Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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32
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Calverley PMA. Guidance for the Better Care of Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2020; 201:1022-1023. [PMID: 32283943 PMCID: PMC7193847 DOI: 10.1164/rccm.202002-0459ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Peter M A Calverley
- Institute of Ageing and Chronic DiseaseUniversity of LiverpoolLiverpool, United Kingdom
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33
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Singh D. Blood Eosinophil Counts in Chronic Obstructive Pulmonary Disease: A Biomarker of Inhaled Corticosteroid Effects. Tuberc Respir Dis (Seoul) 2020; 83:185-194. [PMID: 32578413 PMCID: PMC7362755 DOI: 10.4046/trd.2020.0026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/10/2020] [Indexed: 01/04/2023] Open
Abstract
Blood eosinophil counts have emerged as a chronic obstructive pulmonary disease (COPD) biomarker that predict the effects of inhaled corticosteroids (ICS) in clinical practice. Post-hoc and prospective analysis of randomized control trials have shown that higher blood eosinophil counts at the start of the study predict a greater response to ICS. COPD patients with frequent exacerbations (2 or more moderate exacerbations/yr) or a history of hospitalization have a greater response to ICS. Ex-smokers also appear to have a greater ICS response. Blood eosinophil counts can be combined with clinical information such as exacerbation history and smoking status to enable a precision medicine approach to the use of ICS. Higher blood eosinophil counts are associated with increased eosinophilic lung inflammation, and other biological features that may contribute to the increased ICS response observed. Emerging data indicates that lower blood eosinophil counts are associated with an increased risk of bacterial infection, suggesting complex relationships between eosinophils, ICS response, and the airway microbiome.
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Affiliation(s)
- Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Hospital Trust, Manchester, UK
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34
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Lipworth B, Chan R, RuiWen Kuo C. Observational Data With Inhaled Corticosteroid/Long-Acting Beta-Agonist/Long-Acting Muscarinic Antagonist May Not Reflect Current Practice With Single Triple Inhalers. Chest 2020; 157:1045. [PMID: 32252915 DOI: 10.1016/j.chest.2019.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland.
| | - Rory Chan
- Scottish Centre for Respiratory Research, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland
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35
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Hillas G, Papaporfyriou A, Dimakou K, Papaioannou AI. Pharmacological treatment of stable COPD: need for a simplified approach. Postgrad Med 2020; 132:126-131. [DOI: 10.1080/00325481.2019.1706996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- G. Hillas
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. Papaporfyriou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
| | - K. Dimakou
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. I. Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
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36
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Avdeev SN, Trushenko NV, Merzhoeva ZM, Ivanova MS, Kusraeva EV. [Eosinophilic inflammation in chronic obstructive pulmonary disease]. TERAPEVT ARKH 2019; 91:144-152. [PMID: 32598645 DOI: 10.26442/00403660.2019.10.000426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease that combines various clinical manifestations and pathophysiological mechanisms. It underlies the separation of patients with COPD by phenotypes, endotypes and a personalized therapy of this disease. The implementation of this approach is possible only with the use of appropriate biomarkers. One of the most important biomarkers of COPD is eosinophilia of blood and/or sputum, which is considered as a predictor of frequent exacerbations and the effectiveness of inhaled glucocorticosteroids in patients with COPD. The literature discusses the impact of eosinophilic inflammation on the prognosis, clinical and functional parameters in COPD, and the role of the targeted therapy in the treatment of eosinophilic COPD.
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Affiliation(s)
- S N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Scientific Research Institute
| | - N V Trushenko
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Scientific Research Institute
| | - Z M Merzhoeva
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Scientific Research Institute
| | - M S Ivanova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E V Kusraeva
- Sechenov First Moscow State Medical University (Sechenov University)
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López-Campos JL, Rodríguez DA, Quintana-Gallego E, Martínez-Llorens J, Carrasco Hernández L, Barreiro E. Ten Research Questions for Improving COPD Care in the Next Decade. COPD 2019; 16:311-320. [PMID: 31576763 DOI: 10.1080/15412555.2019.1668919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
With the 60th anniversary of the CIBA symposium, it is worth evaluating research questions that should be prioritized in the future. Coming research initiatives can be summarized in 10 main areas. (1) From epidemiology the impact of new forms of electronic cigarettes on prevalence and mortality of COPD will be sought. (2) The study of the disease endotypes and its relationship phenotypes will have to be unraveled in the next decade. (3) Diagnosis of COPD faces several challenges opening the possibility of a change in the definition of the disease itself. (4) Patients' classification and risk stratification will need to be clarified and reassessed. (5) The asthma-COPD overlap dilemma will have to be clarified and define whether both conditions represent one only chronic airway disease again. (6) Integrating comorbidities in COPD care will be key in a progressively ageing population to improve clinical care in a chronic care model. (7) Nonpharmacological management have areas for research including pulmonary rehabilitation and vaccines. (8) Improving physical activity should focus research because of the clear prognostic impact. (9). Pharmacological therapies present several challenges including efficacy and safety issues with current medications and the development of biological therapy. (10) The definition, identification, categorization and specific therapy of exacerbations will also be an area of research development. During the next decade, we have a window of opportunity to address these research questions that will put us on the path for precision medicine.
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Affiliation(s)
- José Luis López-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
| | - Diego A Rodríguez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, Spain.,Pulmonology Department-Lung Cancer & Muscle Research Group, IMIM (Hospital Del Mar Medical Research Institute), Pompeu Fabra University, Barcelona, Spain
| | - Esther Quintana-Gallego
- 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
| | - Juana Martínez-Llorens
- Pulmonology Department-Lung Cancer & Muscle Research Group, IMIM (Hospital Del Mar Medical Research Institute), Pompeu Fabra University, Barcelona, Spain
| | - Laura Carrasco Hernández
- 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
| | - Esther Barreiro
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, Spain.,Pulmonology Department-Lung Cancer & Muscle Research Group, IMIM (Hospital Del Mar Medical Research Institute), Pompeu Fabra University, Barcelona, Spain
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38
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Martinez FJ, Rabe KF, Calverley PMA, Fabbri LM, Sethi S, Pizzichini E, McIvor A, Anzueto A, Alagappan VKT, Siddiqui S, Reisner C, Zetterstrand S, Román J, Purkayastha D, Bagul N, Rennard SI. Determinants of Response to Roflumilast in Severe Chronic Obstructive Pulmonary Disease. Pooled Analysis of Two Randomized Trials. Am J Respir Crit Care Med 2019; 198:1268-1278. [PMID: 29763572 DOI: 10.1164/rccm.201712-2493oc] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Roflumilast reduces exacerbations in patients with severe chronic obstructive pulmonary disease associated with chronic bronchitis and a history of exacerbations. Further characterization of patients most likely to benefit is warranted. OBJECTIVES Define characteristics that most robustly identify patients who derive greatest exacerbation risk reduction with roflumilast. METHODS Predefined, pooled analyses of REACT (Roflumilast in the Prevention of COPD Exacerbations While Taking Appropriate Combination Treatment; NCT01329029) and RE2SPOND (Roflumilast Effect on Exacerbations in Patients on Dual [LABA/ICS] Therapy; NCT01443845) multicenter, randomized, double-blind, placebo-controlled studies. The primary endpoint was rate of moderate or severe exacerbations per patient per year. MEASUREMENTS AND MAIN RESULTS In the overall intention-to-treat population (n = 4,287), roflumilast reduced moderate or severe exacerbations by 12.3% (rate ratio, 0.88, 95% confidence interval, 0.80-0.97; P = 0.0086) and severe exacerbations by 16.1% (0.84; 0.71-0.99; P = 0.0409) versus placebo. The reduction in moderate or severe exacerbations with roflumilast was most pronounced in patients who had been hospitalized for an exacerbation in the prior year (0.74; 0.63-0.88; P = 0.0005); had more than two exacerbations in the prior year (0.79; 0.65-0.96; P = 0.0160); or had baseline eosinophils ≥150 cells/μl (0.81; 0.71-0.93; P = 0.0020), ≥150 to <300 cells/μl (0.84; 0.71-0.98; P = 0.0282), or ≥300 cells/μl (0.77; 0.61-0.97; P = 0.0264). Similar subgroup results were noted for severe exacerbations. In patients with prior hospitalization and higher baseline blood eosinophil concentrations, roflumilast reduced moderate or severe exacerbations by 34.5% at ≥150 cells/μl (0.65; 0.52-0.82; P = 0.0003) and 42.7% at ≥300 cells/μl (0.57; 0.37-0.88; P = 0.0111) versus placebo. CONCLUSIONS This prespecified, pooled analysis confirms the benefit of roflumilast in decreasing exacerbations in patients with prior hospitalization for exacerbation, greater exacerbation frequency, and higher (≥150 cells/μl, ≥150 to <300 cells/μl, or ≥300 cells/μl) baseline blood eosinophil count.
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Affiliation(s)
| | - Klaus F Rabe
- 2 LungenClinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Peter M A Calverley
- 3 Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Leonardo M Fabbri
- 4 Department of Clinical Medicine, University of Ferrara, Ferrara, Italy.,5 COPD Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sanjay Sethi
- 6 University at Buffalo, State University of New York, Buffalo, New York
| | | | - Andrew McIvor
- 8 McMaster University, Firestone Institute for Respiratory Health, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Antonio Anzueto
- 9 University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, Texas
| | | | | | | | | | | | | | - Nitin Bagul
- 13 Takeda Development Centre Europe Ltd., London, United Kingdom
| | - Stephen I Rennard
- 14 University of Nebraska Medical Center, Omaha, Nebraska; and.,15 Early Clinical Development, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom
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39
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Micheletto C, Braido F, Contoli M, Di Marco F, Santus P. A Framework For Step Down Or Therapeutic Re-Organization For Withdrawal Of Inhaled Corticosteroids In Selected Patients With COPD: A Proposal For COPD Management. Int J Chron Obstruct Pulmon Dis 2019; 14:2185-2193. [PMID: 31576115 PMCID: PMC6765263 DOI: 10.2147/copd.s216059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/09/2019] [Indexed: 01/02/2023] Open
Abstract
While chronic obstructive pulmonary disease (COPD) continues to be a major cause of morbidity and mortality, pharmacological therapy has a definite benefit on symptoms as well as the frequency and severity of exacerbations, and general health. The most recent Global Initiative for Obstructive Lung Disease (GOLD) guidelines recommend triple therapy (long-acting beta2 agonists [LABA] + long-acting muscarinic antagonists [LAMA] + inhaled corticosteroids [ICS]) only for patients with exacerbations, elevated eosinophils, and without control using a LABA/LAMA or ICS/LABA combination. Long-term monotherapy with ICS is not currently recommended, but may be considered in association with LABAs in patients with a history of exacerbations and elevated eosinophils in spite of appropriate treatment with long-acting bronchodilators. However, long-term use of ICS in combination therapy has been associated with adverse effects, even if widely used in routine management for decades. The available evidence suggests that ICS can be rationally discontinued in patients with stable disease and is not likely to have unfavorable effects on lung function, overall health, or be associated with a greater risk of exacerbations. Indeed, it is widely accepted that ICS therapy should be limited to a small proportion of patients after careful assessment of the individual risk-benefit profile. Unfortunately, however, there are no international recommendations that provide specific guidance or a protocol for withdrawal of ICS. Herein, the available evidence on the use of ICS is reviewed and an easy to use tool is proposed that can provide clinicians with a simple management scheme to guide the most appropriate therapy for management of COPD and use of ICS. In management of COPD, a highly personalized approach is advocated so that the most appropriate therapy for each individual patient can be selected.
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Affiliation(s)
- Claudio Micheletto
- Respiratory Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Fulvio Braido
- Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genova, Azienda Policlinico IRCCS San Martino, Genoa, Italy
| | - Marco Contoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università degli Studi di Milano, Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Pierachille Santus
- Department of Health Sciences, Università degli Studi di Milano,Pulmonary Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli, Milan, Italy
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40
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Vukoja M, Kopitovic I, Lazic Z, Milenkovic B, Stankovic I, Zvezdin B, Dudvarski Ilic A, Cekerevac I, Vukcevic M, Zugic V, Hromis S. Diagnosis and management of chronic obstructive pulmonary disease in Serbia: an expert group position statement. Int J Chron Obstruct Pulmon Dis 2019; 14:1993-2002. [PMID: 31564847 PMCID: PMC6730542 DOI: 10.2147/copd.s214690] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/01/2019] [Indexed: 12/26/2022] Open
Abstract
In recent years, several national chronic obstructive pulmonary disease (COPD) guidelines have been issued. In Serbia, the burden of COPD is high and most of the patients are diagnosed at late stages. Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy is poorly implemented in real-life practice, as many patients are still prescribed inhaled corticosteroids (ICS)-containing regimens and slow-release theophylline. In this document, we propose an algorithm for treating COPD patients in Serbia based on national experts’ opinion, taking into account global recommendations and recent findings from clinical trials that are tailored according to local needs. We identified four major components of COPD treatment based on country specifics: active case finding and early diagnosis in high-risk population, therapeutic algorithm for initiation and escalation of therapy that is simple and easy to use in real-life practice, de-escalation of ICS in low-risk non-exacerbators, and individual choice of inhaler device based on patients' ability and preferences. With this approach we aim to facilitate implementation of the recommendation, initiate the treatment in early stages, improve cost-effectiveness, reduce possible side effects, and ensure efficient treatment.
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Affiliation(s)
- Marija Vukoja
- The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Ivan Kopitovic
- The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Zorica Lazic
- Clinic for Pulmonology, Clinical Centre Kragujevac, Kragujevac, Serbia.,Faculty of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Branislava Milenkovic
- Clinic for Pulmonology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Stankovic
- Clinic for Lung Diseases, Clinical Centre of Nis, Nis, Serbia.,Faculty of Medicine, University of Nis, Nis, Serbia
| | - Biljana Zvezdin
- The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Aleksandra Dudvarski Ilic
- Clinic for Pulmonology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Cekerevac
- Clinic for Pulmonology, Clinical Centre Kragujevac, Kragujevac, Serbia.,Faculty of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Miodrag Vukcevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinical Hospital Centre Zemun, Belgrade, Serbia
| | - Vladimir Zugic
- Clinic for Pulmonology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sanja Hromis
- The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
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41
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Calverley PMA. Meeting the GOLD Standard: COPD Treatment in the UK Today. EClinicalMedicine 2019; 14:3-4. [PMID: 31709392 PMCID: PMC6833453 DOI: 10.1016/j.eclinm.2019.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- P M A Calverley
- Institute of Ageing and Chronic Diseases, University of Liverpool, UK
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42
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Vogelmeier CF, Kostikas K, Fang J, Tian H, Jones B, Morgan CL, Fogel R, Gutzwiller FS, Cao H. Evaluation of exacerbations and blood eosinophils in UK and US COPD populations. Respir Res 2019; 20:178. [PMID: 31391053 PMCID: PMC6686508 DOI: 10.1186/s12931-019-1130-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/08/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Blood eosinophil counts and history of exacerbations have been proposed as predictors of patients with chronic obstructive pulmonary disease (COPD) who may benefit from triple therapy (inhaled corticosteroid, long-acting β2-agonist and long-acting muscarinic antagonist). METHODS In a retrospective cohort analysis we examined the profiles of COPD patients from the UK Clinical Practice Research Datalink (CPRD) and US Optum Clinformatics™ Data Mart (Optum) databases with reference to exacerbation frequency and blood eosinophil distribution. RESULTS Of the 31,437 (CPRD) and 383,825 (Optum) patients with COPD, 15,364 (CPRD) and 139,465 (Optum) met the eligibility criteria and were included. Among patients with ≥2 exacerbations and available eosinophil counts in the baseline period (CPRD, n = 3089 and Optum, n = 13414), 17.0 and 13.3% respectively had eosinophil counts ≥400 cells/μL. Patients with ≥2 exacerbations or eosinophil count ≥400 cells/μL during first year, exacerbated at least once (CPRD, 82.8% vs Optum, 80.6%) or continued to have eosinophil count ≥300 cells/μL (76.8% vs 76.5%), respectively in the follow-up year. In both years, a higher variability in the number of exacerbations and eosinophil count was observed in patients with one exacerbation and eosinophil counts between 300 and 400 cells/μL; patients with eosinophil count < 150 cells/μL had the lowest variability. Approximately 10% patients had both ≥2 exacerbations and eosinophil count ≥300 cells/μL across the databases. CONCLUSION A high variability in blood eosinophil counts over two consecutive years was observed in UK and US patients with COPD and should be considered while making treatment decisions. A small proportion of COPD patients had frequent exacerbations and eosinophil count ≥300 cells/μL.
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Affiliation(s)
- Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University Marburg, Member of the German Center for Lung Research (DZL), 35043, Marburg, Germany.
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Juanzhi Fang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | | | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Hui Cao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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43
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López-Campos JL, Soler-Cataluña JJ, Miravitlles M. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2019 Report: Future Challenges. Arch Bronconeumol 2019; 56:65-67. [PMID: 31320191 DOI: 10.1016/j.arbres.2019.06.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/31/2019] [Accepted: 06/05/2019] [Indexed: 11/30/2022]
Affiliation(s)
- José 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; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | | | - Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron/Vall d'Hebron Institut de Recerca, Barcelona, Spain
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44
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Pascoe S, Barnes N, Brusselle G, Compton C, Criner GJ, Dransfield MT, Halpin DMG, Han MK, Hartley B, Lange P, Lettis S, Lipson DA, Lomas DA, Martinez FJ, Papi A, Roche N, van der Valk RJP, Wise R, Singh D. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:745-756. [PMID: 31281061 DOI: 10.1016/s2213-2600(19)30190-0] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 04/05/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous studies have highlighted a relationship between reduction in rate of exacerbations with therapies containing inhaled corticosteroids (ICS) and baseline blood eosinophil count in patients with chronic obstructive pulmonary disease (COPD). The IMPACT trial showed that once-daily single-inhaler triple therapy significantly reduced exacerbations versus dual therapies. Blood eosinophil counts and smoking status could be important modifiers of treatment response to ICS. We aimed to model these relationships and their interactions, including outcomes other than exacerbations. METHODS IMPACT was a phase 3, randomised, double-blind, parallel-group, 52-week global study comparing once-daily single-inhaler triple therapy (fluticasone furoate-umeclidinium-vilanterol) with dual inhaled therapy (fluticasone furoate-vilanterol or umeclidinium-vilanterol). Eligible patients had moderate-to-very-severe COPD and at least one moderate or severe exacerbation in the previous year. We used fractional polynomials to model continuous blood eosinophil counts. We used negative binomial regression for numbers of moderate and severe exacerbations, severe exacerbations, and pneumonia. We modelled differences at week 52 in trough FEV1, St George's Respiratory Questionnaire (SGRQ) total score, and Transition Dyspnoea Index using repeated measurements mixed effect models. IMPACT was registered with ClinicalTrials.gov, number NCT02164513. FINDINGS The magnitude of benefit of regimens containing ICS (fluticasone furoate-umeclidinium-vilanterol n=4151 and fluticasone furoate-vilanterol n=4134) in reducing rates of moderate and severe exacerbations increased in proportion with blood eosinophil count, compared with a non-ICS dual long-acting bronchodilator (umeclidinium-vilanterol n=2070). The moderate and severe exacerbation rate ratio for triple therapy versus umeclidinium-vilanterol was 0·88 (95% CI 0·74 to 1·04) at blood eosinophil count less than 90 cells per μL and 0·56 (0·47 to 0·66) at counts of 310 cells per μL or more; the corresponding rate ratio for fluticasone furoate-vilanterol versus umeclidinium-vilanterol was 1·09 (0·91 to 1·29) and 0·56 (0·47 to 0·66), respectively. Similar results were observed for FEV1, Transition Dyspnoea Index, and SGRQ total score; however, the relationship with FEV1 was less marked. At blood eosinophil counts less than 90 cells per μL and at counts of 310 cells per μL or more, the triple therapy versus umeclidinium-vilanterol treatment difference was 40 mL (95% CI 10 to 70) and 60 mL (20 to 100) for trough FEV1, -0·01 (-0·68 to 0·66) and 0·30 (-0·37 to 0·97) for Transition Dyspnoea Index score, and -0·01 (-1·81 to 1·78) and -2·78 (-4·64 to -0·92) for SGRQ total score, respectively. Smoking status modified the relationship between observed efficacy and blood eosinophil count for moderate or severe exacerbations, Transition Dyspnoea Index, and FEV1, with former smokers being more corticosteroid responsive at any eosinophil count than current smokers. INTERPRETATION This analysis of the IMPACT trial shows that assessment of blood eosinophil count and smoking status has the potential to optimise ICS use in clinical practice in patients with COPD and a history of exacerbations. FUNDING GlaxoSmithKline.
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Affiliation(s)
| | - Neil Barnes
- GlaxoSmithKline, Brentford, UK; Barts and the London School of Medicine and Dentistry, London, UK
| | | | | | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - MeiLan K Han
- University of Michigan, Pulmonary & Critical Care, Ann Arbor, MI, USA
| | | | - Peter Lange
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark; Medical Department, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - David A Lipson
- GlaxoSmithKline, Collegeville, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Lomas
- UCL Respiratory, University College London, Gower Street, London, UK
| | | | - Alberto Papi
- Research Centre on Asthma and COPD, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Nicolas Roche
- Pneumologie, Cochin Hospital AP-HP, University Paris Descartes, Paris, France
| | | | - Robert Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Dave Singh
- University of Manchester, Manchester, UK
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Abstract
Chronic obstructive pulmonary disease (COPD) is a major global health problem that is poorly treated by current therapies as it has proved difficult to treat the underlying inflammation, which is largely corticosteroid-resistant in most patients. Although rare genetic endotypes of COPD have been recognized, despite the clinical heterogeneity of COPD, it has proved difficult to identify distinct inflammatory endotypes. Most patients have increased neutrophils and macrophages in sputum, reflecting the increased secretion of neutrophil and monocyte chemotactic mediators in the lungs. However, some patients also have increased eosinophils in sputum and this may be reflected by increased blood eosinophils. Increased blood and sputum eosinophils are associated with more frequent exacerbations and predict a good response to corticosteroids in reducing and treating acute exacerbations. Eosinophilic COPD may represent an overlap with asthma but the mechanism of eosinophilia is uncertain as, although an increase in sputum IL-5 has been detected, anti-IL-5 therapies are not effective in preventing exacerbations. More research is needed to link inflammatory endotypes to clinical manifestations and outcomes in COPD and in particular to predict response to precision medicines.
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Affiliation(s)
- Peter J. Barnes
- National Heart and Lung Institute Imperial College London UK
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46
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Oshagbemi OA, Franssen FME, van Kraaij S, Braeken DCW, Wouters EFM, Maitland-van der Zee AH, Driessen JHM, de Vries F. Blood Eosinophil Counts, Withdrawal of Inhaled Corticosteroids and Risk of COPD Exacerbations and Mortality in the Clinical Practice Research Datalink (CPRD). COPD 2019; 16:152-159. [PMID: 31117850 DOI: 10.1080/15412555.2019.1608172] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although recently introduced in the pharmacological treatment algorithm of chronic obstructive pulmonary disease (COPD), there is a need for more data supporting the use of blood eosinophil counts as a biomarker to guide inhaled corticosteroids (ICS) therapy. The aim of this study was to evaluate the risk of moderate and/or severe exacerbations and all-cause mortality in a large primary care population after withdrawal of ICS compared to continued users stratified by elevated blood eosinophil counts. In this population based cohort study, we used data from the Clinical Practice Research Datalink (CPRD) in the United Kingdom. We included subjects' aged 40 years or more who had a diagnosis of COPD. We excluded subjects with a history of asthma, pulmonary fibrosis, cardiac arrhythmia and bronchiectasis, COPD exacerbations occurring within 6 weeks prior to index date, or with a myocardial infarction within 3 months prior to index date. Continuous users were subjects who received their most recent ICS prescription within 3 months before the start of an interval. ICS withdrawals were those who discontinued ICS for more than 3 months. We evaluated the risk of moderate and/or severe exacerbations and all-cause mortality among subjects with various blood eosinophil thresholds who withdrew from ICS compared to continuous ICS users with elevated blood eosinophil levels using Cox regression analysis adjusted for potential confounders. We identified 48,157 subjects diagnosed with COPD between 1 January 2005 to 31 January 2014. Withdrawal of ICS was not associated with an increased risk of moderate-to-severe exacerbations among subjects with absolute blood eosinophil counts ≥0.34 × 109 cells/L [adjusted hazard ratio (adj. HR) 0.72; 95% confidence interval (CI) 0.63-0.81] or relative counts ≥ 4.0% (adj. HR 0.72; 95% CI: 0.66-0.78). Similarly, withdrawal of ICS was not associated with an increased risk of severe exacerbations among subjects with absolute blood eosinophil ≥0.34 × 109 cells/L (adj. HR 0.82; 95% CI: 0.61-1.10) or relative blood eosinophil counts ≥4.0% (adj. HR 0.80; 95% CI: 0.61-1.04). No increased risk of all-cause mortality was observed among subjects who withdrew from ICS irrespective of elevated absolute or relative blood eosinophil counts. In a real-world primary care population, we did not observe an increased risk of moderate and/or severe COPD exacerbations or all-cause mortality among subjects with eosinophilia who withdrew their use of ICS.
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Affiliation(s)
- Olorunfemi A Oshagbemi
- a Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre , Maastricht , the Netherlands.,b Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University , Maastricht , the Netherlands.,c Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences , Utrecht , the Netherlands.,d CIRO , Horn , the Netherlands
| | - Frits M E Franssen
- d CIRO , Horn , the Netherlands.,e Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+) , Maastricht , the Netherlands
| | - Suzanne van Kraaij
- a Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre , Maastricht , the Netherlands
| | - Dionne C W Braeken
- c Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences , Utrecht , the Netherlands.,d CIRO , Horn , the Netherlands.,e Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+) , Maastricht , the Netherlands
| | - Emiel F M Wouters
- d CIRO , Horn , the Netherlands.,f Department of Respiratory Medicine, Academic Medical Centre (AMC), University of Amsterdam (UvA) Amsterdam , the Netherlands
| | - Anke H Maitland-van der Zee
- c Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences , Utrecht , the Netherlands.,f Department of Respiratory Medicine, Academic Medical Centre (AMC), University of Amsterdam (UvA) Amsterdam , the Netherlands
| | - Johanna H M Driessen
- a Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre , Maastricht , the Netherlands.,c Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences , Utrecht , the Netherlands.,g NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University , Maastricht , the Netherlands
| | - Frank de Vries
- a Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre , Maastricht , the Netherlands.,b Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University , Maastricht , the Netherlands.,c Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences , Utrecht , the Netherlands
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Singh D, Agusti A, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, Criner GJ, Frith P, Halpin DMG, Han M, López Varela MV, Martinez F, Montes de Oca M, Papi A, Pavord ID, Roche N, Sin DD, Stockley R, Vestbo J, Wedzicha JA, Vogelmeier C. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J 2019; 53:13993003.00164-2019. [PMID: 30846476 DOI: 10.1183/13993003.00164-2019] [Citation(s) in RCA: 1024] [Impact Index Per Article: 204.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/22/2019] [Indexed: 12/17/2022]
Abstract
Precision medicine is a patient-specific approach that integrates all relevant clinical, genetic and biological information in order to optimise the therapeutic benefit relative to the possibility of side-effects for each individual. Recent clinical trials have shown that higher blood eosinophil counts are associated with a greater efficacy of inhaled corticosteroids (ICSs) in chronic obstructive pulmonary disease (COPD) patients. Blood eosinophil counts are a biomarker with potential to be used in clinical practice, to help target ICS treatment with more precision in COPD patients with a history of exacerbations despite appropriate bronchodilator treatment.The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 pharmacological treatment algorithms, based on the ABCD assessment, can be applied relatively easily to treatment-naive individuals at initial presentation. However, their use is more problematic during follow-up in patients who are already on maintenance treatment. There is a need for a different system to guide COPD pharmacological management during follow-up.Recent large randomised controlled trials have provided important new information concerning the therapeutic effects of ICSs and long-acting bronchodilators on exacerbations. The new evidence regarding blood eosinophils and inhaled treatments, and the need to distinguish between initial and follow-up pharmacological management, led to changes in the GOLD pharmacological treatment recommendations. This article explains the evidence and rationale for the GOLD 2019 pharmacological treatment recommendations.
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Affiliation(s)
- Dave Singh
- University of Manchester, Manchester, UK
| | - Alvar Agusti
- Hospital Clínic, Universitat de Barcelona, CIBERES, Barcelona, Spain
| | - Antonio Anzueto
- University of Texas Health Science Center, San Antonio, TX, USA
| | | | - Jean Bourbeau
- McGill University Health Centre, Montreal, QC, Canada
| | | | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Peter Frith
- Flinders University College of Medicine and Public Health, Adelaide, Australia
| | | | - Meilan Han
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | | | - Fernando Martinez
- New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | | | - Alberto Papi
- Cardiorespiratory and Internal Medicine Unit, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Ian D Pavord
- Respiratory Medicine Unit, Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, Oxford, UK
| | - Nicolas Roche
- Hôpital Cochin (AP-HP), University Paris Descartes, Paris, France
| | - Donald D Sin
- University of British Columbia, Vancouver, BC, Canada
| | | | | | | | - Claus Vogelmeier
- Dept of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps University Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
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Pires N, Pinto P, Marçal N, Ferreira A, Rodrigues C, Bárbara C. Pharmacological treatment of COPD – New evidence. Pulmonology 2019; 25:90-96. [DOI: 10.1016/j.pulmoe.2018.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/14/2018] [Indexed: 10/27/2022] Open
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Inhaled corticosteroids and fractures in chronic obstructive pulmonary disease. Curr Opin Pulm Med 2019; 25:165-172. [DOI: 10.1097/mcp.0000000000000554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Gaduzo S, McGovern V, Roberts J, Scullion JE, Singh D. When to use single-inhaler triple therapy in COPD: a practical approach for primary care health care professionals. Int J Chron Obstruct Pulmon Dis 2019; 14:391-401. [PMID: 30863039 PMCID: PMC6388781 DOI: 10.2147/copd.s173901] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
While single-inhaler triple therapy (SITT) devices were not available when the Global Initiative for Chronic Obstructive Lung Disease strategy and National Institute for Health and Care Excellence guidelines were developed, two devices are now available in the UK. This paper offers practical, patient-focused advice to optimize placement of SITT in the management of COPD. A survey of UK health care professionals (HCPs) identified issues around, and attitudes toward, SITT, which informed a multidisciplinary expert panel’s discussions. The survey confirmed the need to clarify the place of SITT in COPD management. The panel suggested three criteria, any one of which identifies a high-risk patient where escalation to triple therapy from monotherapy or double combination treatment is appropriate: 1) at least two exacerbations treated with oral corticosteroids, antibiotics, or both in the previous year; 2) at least one severe exacerbation that required hospital admission in the previous year; 3) one exacerbation a year on a repeated basis for 2 consecutive years. Appropriate non-pharmacological management is essential for all patients and should be considered before stepping up treatment. Regular review is essential. During each review, HCPs should consider stepping treatment up or down. If patients exacerbate despite adhering to triple therapy, an individualized approach should be considered if the inhaled corticosteroid (ICS) confers benefit or causes side effects. In this situation, the blood eosinophil count could aid decision making. ICSs should be continued when the history suggests that asthma overlaps with COPD. Training, counseling, and education should be individualized. HCPs should consider referral: 1) when there is limited response to treatment and persistent exacerbations; 2) where there is diagnostic uncertainty or suspected comorbidity; 3) whenever they feel “out of their depth.” Overall, the panel concurred that when used correctly, SITT has the potential to improve adherence, symptom control, and quality of life, and reduce exacerbations. Studies using real-world evidence need to confirm these benefits.
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Affiliation(s)
- S Gaduzo
- Stockport NHS Foundation Trust, Stockport, UK
| | | | - J Roberts
- Salford Royal NHS Foundation Trust, Salford, UK
| | - J E Scullion
- University Hospitals of Leicester, Leicester, UK
| | - D Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospital Trust, Manchester, UK,
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