Reduction in All-Cause Mortality with Fluticasone Furoate/Umeclidinium/Vilanterol in Patients with Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD): Developments in Pharmacological Treatments

The immediate goals of pharmacological management in chronic obstructive pulmonary disease (COPD) are to minimise symptoms and improve exercise performance. The longer-term goals are to reduce the future risk of exacerbations, lung function decline and mortality. It is now recognised that a subset of COPD patients have type 2 inflammation, which is identified by the presence of higher blood eosinophil counts (BEC). Individuals with higher BEC show a greater response to pharmacological interventions targeting type 2 inflammation, including inhaled corticosteroids and the monoclonal antibody, dupilumab. The use of BEC as a biomarker to guide pharmacological treatment has enabled a precision medicine approach in COPD. This article reviews recent advances in the pharmacological treatment of COPD, encompassing the optimum use of inhaled combination treatments and the evidence to support the use of the novel inhaled phosphodiesterase inhibitor ensifentrine and monoclonal antibodies in patients with COPD.

Prevalence of microspirometry-detected chronic obstructive pulmonary disease in two European cohorts of patients hospitalised for acute myocardial infarction: a cross-sectional study

OBJECTIVES

To establish the prevalence of clinically significant chronic obstructive pulmonary disease (COPD) and relevant characteristics in individuals with a significant smoking history who are hospitalised for acute myocardial infarction (MI).

DESIGN

Cross-sectional study.

SETTING

Hospital inpatients at 8 European centres (7 in Sweden, 1 in the UK).

PARTICIPANTS

518 men or women (302 in Sweden, 216 in the UK) hospitalised for acute MI, aged 40 years or older, with a smoking history of at least 10 pack-years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was prevalence of detected significant COPD (Global Initiative for Chronic Obstructive Lung Disease stages 2-4), defined as a ratio of forced expiratory volume in 1 and 6 s (FEV1/FEV6) <0.7 and FEV1 <80% of the predicted value, measured using microspirometry. Secondary outcome measures were prior diagnosis of COPD, prescription of inhaled corticosteroids (ICS), symptom burden (COPD Assessment Test (CAT)) and blood eosinophil count.

RESULTS

The prevalence of significant COPD was 91/518 (18% (95% CI 14 to 21)) with no difference between the countries. Of those with detected significant COPD, 69 (76%) had no previous COPD diagnosis. A CAT score >10 was found in 65%, and a blood eosinophil count of ≥100/mm3 and ≥300/mm3 was found in 76% and 20%, respectively. Inhaled corticosteroids were used by 15% of the patients.

CONCLUSIONS

In a cohort of patients hospitalised for acute MI in Sweden and the UK, one in five patients with a history of smoking was found to have significant COPD based on microspirometry. Symptom burden was high and treatment rates with ICS low. Among those diagnosed with COPD, three out of four had not been previously diagnosed with COPD.

Risk trajectory of cardiovascular events after an exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) are known to increase the risk of cardiovascular (CV) events and mortality. However, the temporal trend of this risk has not fully elucidated. This systematic review and meta-analysis aims to quantify the risk of CV events after COPD exacerbations over different time periods.

OBJECTIVES

To assess the temporal association between CV events, including acute coronary syndrome (ACS), heart failure (HF), acute cereberovascular events, arrhythmia and all-cause mortality after the onset of COPD exacerbations in the following timepoints: 1-30 and 31-180 days; 1-7, 8-14, 15-30, 31-180, 181-365 and >365 days.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, Web of Science and Cochrane databases, identifying observational studies that reported CV outcomes following COPD exacerbations. Studies were included if they enrolled adults diagnosed with COPD and compared CV event rates during exacerbation and non-exacerbation periods (PROSPERO, CRD42024561490).

RESULTS

Sixteen studies with over 1.8 million participants were included. Our meta-analysis demonstrated a significantly increased risk of ACS, HF, cerebrovascular events and arrhythmia, with the highest magnitude of risk observed in the period 1-30 days following an exacerbation. This increased risk showed a decline in time points 31-180, 181-365 days and remained persistently higher for ACS even one year after an acute exacerbation. Notably, the risk of HF was found to be greater compared to the other CV outcomes.

CONCLUSION

COPD exacerbations significantly increase the risk of acute CV events, particularly within the first 30 days. Optimal strategies to reduce cardiopulmonary risk are needed.

Characteristics of Patients Initiated on Budesonide/Glycopyrronium Bromide/Formoterol Fumarate Single Inhaler Triple Therapy for the Treatment of Chronic Obstructive Pulmonary Disease: A Population-Based Observational Study

Background

Budesonide/glycopyrronium bromide/formoterol fumarate (BUD/GLY/FOR) single inhaler triple therapy became available to prescribe to patients with severe chronic obstructive pulmonary disease (COPD) in France in 2021. The characteristics of patients prescribed BUD/GLY/FOR triple therapy and guideline adherence have not been previously described in France.

Objective

To describe the characteristics of COPD patients initiated on BUD/GLY/FOR triple therapy, assess adherence to COPD management guidelines, and explore any differences by prescribing physician.

Materials and Methods

A cross-sectional study using data from The Health Improvement Network (THIN®) France database was conducted. Patients with ≥2 recorded diagnostic codes for COPD were included. Demographic characteristics, comorbidities, management, COPD-related characteristics, and guideline adherence (Société de Pneumologie de Langue Française (SPLF); Haute Autorité de Santé (HAS)), stratified by initiating physician speciality (general practitioner (GP) or pulmonologist) were described.

Results

A total of 263 patients initiating BUD/GLY/FOR triple therapy were included. Mean (SD) age was 68.8 (11.8) years; 53.6% were male. Mean (SD) COPD duration was 6.4 (5.5) years. Comorbidities were common, with slightly more cardiometabolic and mental health conditions recorded in the GP-initiated group, and more comorbid respiratory conditions recorded in the pulmonologist-initiated group. About 77.2% (n=203) of patients had at least one moderate or severe exacerbation in the 12 months before initiation. About 86.3% had a previous record of dual (n=117, 44.5%) or triple (n=110, 41.8%) therapy. About 68.8% had been initiated on BUD/GLY/FOR triple therapy in line with SPLF guidelines (62.4% and 72.4% in the GP- and pulmonologist-initiated groups, respectively); among those with a record of COPD severity, 75.2% were initiated in line with HAS guidelines (69.2% and 76.3% in the GP- and pulmonologist-initiated groups, respectively).

Conclusion

The majority of COPD patients are prescribed BUD/GLY/FOR triple therapy in accordance with current treatment guidelines, irrespective of whether the therapy is prescribed by a general practitioner or a pulmonologist.

Effectiveness of Single Versus Multiple Inhaler Triple Therapy on Mortality and Cardiopulmonary Risk Reduction in COPD: The SKOPOS-MAZI Study

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) have elevated cardiopulmonary and mortality risk, particularly following exacerbations. While single inhaler triple therapies (SITTs), such as budesonide/glycopyrrolate/formoterol fumarate (BGF), reduce cardiopulmonary risk versus dual bronchodilator therapy, there is limited evidence comparing outcomes with SITTs versus multiple inhaler triple therapies (MITTs).

METHODS

SKOPOS-MAZI was a retrospective comparative effectiveness study in patients with COPD aged ≥40 years using US administrative claims data from Optum's deidentified Clinformatics® Data Mart Database. The primary and secondary endpoints were time to all-cause mortality and time to first severe cardiopulmonary event following initiation of BGF or MITT (identification period: October 1, 2020-June 30, 2023; index date: first prescription fill). Relative hazards of outcomes were assessed until a censoring event using Cox proportional hazards models, with inverse propensity treatment weighting accounting for between-group imbalances (standardized mean difference >0.1) in baseline characteristics.

RESULTS

In the primary cohort, risk (hazard ratio [95% confidence intervals]) of all-cause mortality and a first severe cardiopulmonary event were 18% (0.82 [0.75, 0.91]) and 12% (0.88 [0.83, 0.93]) lower in patients initiating BGF versus MITT; results were consistent across censoring definitions, landmark periods, and sensitivity cohorts.

CONCLUSION

In this real-world comparative effectiveness study of patients with COPD initiating BGF or MITT, BGF was associated with lower all-cause mortality and severe cardiopulmonary event risk versus MITT after accounting for between-group differences in baseline sociodemographic and clinical characteristics. This study supports the benefits of BGF over MITT and the need to consider proactive use of SITTs in COPD management.

The Intersection of Chronic Obstructive Pulmonary Disease and Cardiovascular Disease: Recent Insights in a Challenging Area

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) are 2 prevalent and interconnected health conditions that have a significant global impact. COPD is characterized by airflow obstruction and is caused by smoking and/or environmental factors. COPD is associated with chronic inflammation and structural changes in the airways and lung parenchyma. CVD encompasses various cardiac and vascular conditions and is a leading global cause of mortality, with risk factors that include diabetes, smoking, and dyslipidemia. CVDs discussed in this review, in relation to COPD, include hypertension, coronary artery disease and ischemic heart disease, heart failure, cardiac arrhythmias, and cerebrovascular disease. The interplay between COPD and CVD is evident, with shared risk factors and physiological mechanisms contributing to their frequent comorbidity. Therefore, an integrated approach to care involving primary care physicians, respirologists, and cardiologists is essential to effectively manage the dual burden of COPD and CVD. This review outlines the shared risks and underlying mechanisms of these conditions, their diagnosis, and the clinical implications of dual COPD and CVD in a patient, including how COPD exacerbations significantly elevate the risk of cardiovascular (CV) events and mortality. Pharmacologic CVD and COPD therapies, as well as their CV and respiratory effects, are discussed. Key trials (Towards a Revolution in COPD Health [TORCH]; Study to Understand Mortality and Morbidity in COPD [SUMMIT]; InforMing the Pathway of COPD Treatment [IMPACT]; and Efficacy and Safety of Triple Therapy in Obstructive Lung Disease [ETHOS]) are discussed that demonstrate the effectiveness of triple bronchodilator therapy in reducing exacerbation rates, as well as all-cause and cardiovascular mortality in patients with COPD and CVD. Overall, this review highlights the need for an integrated approach to patient management, involving collaboration among primary care physicians, respirologists, and cardiologists, to effectively address the dual burden of these diseases.

Nasal production of IL-26 involving T cells in smokers with and without chronic obstructive pulmonary disease

BACKGROUND

Novel specific therapy in chronic obstructive pulmonary disease (COPD) will require accessible targets for endotyping to identify responsive patients. It is therefore of interest that IL-26 in the bronchoalveolar space is enhanced and associates with bronchoalveolar pathology among long-term smokers (LTS) with and without COPD.

OBJECTIVE

We determined whether IL-26 in the nasal cavity can be produced by T cells and associates with bronchoalveolar pathology and clinical symptoms in LTS with and without COPD.

METHODS

We characterized LTS with and without COPD plus healthy nonsmokers by radiology, spirometry, modified Medical Research Council scale, and St George Respiratory Questionnaire. We determined extracellular IL-26 concentrations (via ELISA) in nasal (NAL) and bronchoalveolar lavage (BAL) samples, BAL neutrophil counts, and NAL IL-26+ T-cell expression (via flow cytometry).

RESULTS

The NAL IL-26 concentrations were higher in LTS with COPD than in healthy nonsmokers. These enhanced IL-26 concentrations displayed a positive correlation with forced expiratory volume in 1 second/forced vital capacity ratio. The IL-26 protein was expressed in CD4+ and CD8+ T cells, but only a small portion of these cells coexpressed IL-15, IL-17A, or IL-22 in LTS with COPD. In this group, IL-26+ CD3+ T cells displayed a negative correlation with forced expiratory volume in 1 second, as did with extracellular NAL IL-26 concentrations. The relative mean fluorescence intensity for CD8+ T cells displayed a negative correlation with modified Medical Research Council and St George Respiratory Questionnaire score.

CONCLUSION

In the nasal cavity, IL-26 can be produced by local T cells. This IL-26 reflects bronchoalveolar pathology and clinical symptoms, thereby constituting an accessible target with potential for clinically relevant endotyping in COPD.

Effect of triple inhaled therapy on cardiovascular and all-cause mortality compared with dual inhaled therapy in COPD: A systematic review and meta-analysis

BACKGROUND

There is uncertainty about the role of triple inhaled therapy with LAMA/LABA/ICS (long-acting muscarinic antagonist/long-acting β2-agonist/inhaled glucocorticoids) in chronic obstructive pulmonary disease (COPD) on cardiovascular mortality. We estimated the effect of triple inhaled therapy (TT) compared with dual inhaled therapy (DT, including either LAMA/LABA or LABA/ICS) on all-cause and cardiovascular mortality in an evidence synthesis, METHODS: Following prospective registration (https://osf.io/gtfvm), a comprehensive search strategy of PubMed, Scopus, and Embase was performed, without language or time restrictions until September 30, 2024. All randomized clinical trials (RCTs) evaluating TT vs. DT and reporting cardiovascular or all-cause mortality were included. We assessed risk of bias and conducted a random effect meta-analysis estimating summary relative risk (RR) with 95% confidence intervals (CI), evaluating heterogeneity using I2. A network meta-analysis (NMA) was undertaken to hierarchically rank the therapies using P-score.

RESULTS

From 781 citations, 5 RCTs were selected. There were 3 three-arm RCTs comparing TT vs. LABA/ICS vs. LAMA/LABA, 1 two-arm RCT comparing TT vs. LABA/ICS, and 1 two-arm RCT comparing TT vs. LAMA/LABA (total of 7855 patients receiving TT, 7003 LABA/ICS and 5059 LAMA/LABA). The risk of bias was moderate in 2 (40%), and low in 3 (60%) RCTs. TT reduced cardiovascular mortality by 48% vs. LAMA/LABA (RR 0.52, 95% CI 0.32-0.86, 3 RCTs, I2=0%) and by a non-significant 11% vs. LABA/ICS (RR 0.89, 95% CI 0.57-1.37, 3 RCTs, I2=0%). TT reduced all-cause mortality by 34% vs. LAMA/LABA (RR 0.66, 95% CI 0.48-0.90, 4 RCTs, I2=23.7%) and by 10% vs. LABA/ICS (RR 0.90, 95% CI 0.71-1.13, 4 RCTs, I2=0%). For both cardiovascular and all-cause mortality, NMA P-score showed that TT ranked first (81%/91%), LABA/ICS ranked second (58%/57%) and LAMA/LABA ranked last (11%/<1%) in effectiveness.

CONCLUSIONS

In patients with moderate to very severe COPD and previous exacerbations, TT inhaled significantly reduces cardiovascular and all-cause mortality compared to LAMA/LABA dual therapy, but not when compared to LABA/ICS.

Access to single-inhaler triple medicines for chronic obstructive pulmonary disease in China: a national survey on accessibility and utilisation

Background

The maintenance medicines for chronic obstructive pulmonary disease (COPD) include inhaled corticosteroids (ICS), long-acting muscarinic antagonists (LAMA) and long-acting β2-agonists (LABA). Budesonide/glycopyrronium/formoterol (BUD/GLY/FOR) and fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) are two representative drugs for prefixed ICS/LAMA/LABA association in a single inhaler and have shown comparable efficacy and safety with other ICS/LAMA/LABA open combination therapies in patients with moderate-to-very severe COPD. This study aimed to investigate the availability, price, affordability, and utilisation of single-inhaler triple medicines for COPD in China.

Methods

Quarterly data about the use of BUD/GLY/FOR and FF/UMEC/VI from 2020 to 2022 were collected from the Chinese Medicine Economic Information Network. We used the adjusted World Health Organization and Health Action International methodology to calculate the availability and affordability of the two investigated medicines in 596 tertiary general hospitals and 299 secondary general hospitals in 31 provincial administrative regions in China.

Results

The availability and consumption of BUD/GLY/FOR were significantly higher than those of FF/UMEC/VI during the study period. At the end of 2022, the availability of BUD/GLY/FOR and FF/UMEC/VI in tertiary general hospitals was 69.80% and 52.01% respectively, while in secondary general hospitals, it was 52.51% and 28.76% respectively. Both medications were equally affordable at 1.3 days of the minimum wage after reimbursement in 2022. In the first quarter of 2021, with the inclusion of both drugs in the Medicare catalog, their DDDc decreased significantly, which was accompanied by notable improvements in their availability, affordability and consumption.

Conclusions

The overall accessibility and consumption of BUD/GLY/FOR and FF/UMEC/VI were improved in China from 2020 to 2022. The implementation of the national drug price negotiation policy reduces the cost of drugs in China and plays an important role in improving the availability of the investigated drugs.

Delaying disease progression in COPD with early escalation to triple therapy: a modelling study (DEPICT-2)

Introduction

In patients with COPD, dual bronchodilator (long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA)) and triple therapy (inhaled corticosteroid/LAMA/LABA) reduce the risk of exacerbations and lung function decline in the short-mid-term, but their long-term impact is unknown. This modelling study explores long-term impact of these therapies on lung function decline, quality of life (QoL) and all-cause mortality.

Methods

This modelling approach used a longitudinal nonparametric superposition model using published data regarding exacerbations, QoL (assessed by St George's Respiratory Questionnaire (SGRQ)) and mortality. The model simulated disease progression from 40 to 75 years of age and assessed the impact of initiating dual bronchodilator at age 45 years ("LAMA/LABA only" group) and escalation to triple therapy at age 50 years ("Escalation to triple" group) on forced expiratory volume in 1 s (FEV1) decline, QoL and mortality.

Results

Model simulation predicted that by 75 years of age, "LAMA/LABA only" preserves 159.1 mL of FEV1 versus no treatment, while "Escalation to triple" preserves an additional 376.5 mL and 217.3 mL of FEV1 versus no pharmacotherapy and "LAMA/LABA only", respectively. In "LAMA/LABA only", the SGRQ score reduces (-3.2) versus no treatment, which further reduces to -7.5 in "Escalation to triple". In "LAMA/LABA only", mortality reduces by 5.4% by 75 years versus no treatment, while the "Escalation to triple" shows further decrease in mortality by 12.0%.

Conclusion

Early pharmacotherapy initiation and escalation from dual bronchodilator to triple therapy could slow disease progression by preserving lung function and improving QoL and survival in patients with COPD.

Two for the price of one: GLP-1 analogues, a new approach in treating severe COPD patients with diabetes

Multimorbid severe COPD patients need to be treated with a complementary systemic approach. In this way, the patient, not only the airway disease, will be treated comprehensively, as two effects (metabolic and pulmonary) are better than one. https://bit.ly/3PHoygt.

Is Disease Stability an Attainable Chronic Obstructive Pulmonary Disease Treatment Goal?

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition characterized by progressive airflow obstruction. Despite advancements in diagnosis and treatment, the disease burden remains high; although clinical trials have shown improvements in outcomes such as exacerbations, quality of life, and lung function, improvement may not be attainable for many patients. For patients who do experience improvement, it is challenging to set management goals given the progressive nature of COPD. We therefore propose disease stability as an appropriate and attainable treatment goal. Other disease areas have developed definitions of no disease activity or remission, which provide relevant information for defining and achieving stability for patients with COPD. Disease stability builds on related concepts already defined in COPD, such as clinical control and clinically important deterioration. Current components that could form part of a disease stability definition include exacerbations, health status (including quality of life and symptoms), and lung function. Considerations should be given to intervals over which stability is defined and assessed, appropriate thresholds, and defining a composite. Ensuring a holistic approach, objective measurements, and harmonious, clear communication between patients and physicians can further support establishing disease stability. Here we propose a preliminary definition of disease stability, informed by existing research in COPD. Further research will be needed to validate the framework for use in clinical and research settings. Exploring disease stability as a goal, however, is an opportunity to develop and validate an attainable treatment target to advance the standard of care for patients with COPD.

Inhalation treatment of chronic obstructive pulmonary disease (COPD) in older patients

Chronic obstructive pulmonary disease (COPD) is frequent in older patients. Frailty, cognitive impairment and sarcopenia are predictors for inadequately performed lung function testing as well as presenting challenges in subsequent disease management. Underdiagnosis and suboptimal treatment are often the result of incomplete assessment of older COPD patients. Problems associated with older COPD patients are not adequately addressed in international guidelines, although numerous evidence-based strategies are available. A key aspect is the management of the various inhaler devices. Up to 60-80% of older patients with COPD do not use the inhalers correctly. Even when the inhaler technique is correct, there is undertreatment if the required inspiratory flow cannot be achieved. Given the high rate of suboptimal inhaler treatment in older patients with COPD, an analysis of the pitfalls is important. An objective measurement of inspiratory flow and assessment of cognition and coordination are essential. A possible clinical algorithm for the assessment of older patients with respect to inhaler treatment of COPD is presented in a consensus approach by the Pneumological Geriatric Medicine Working Group of the German Society of Pulmonologists.

The cardiovascular effects of long-acting bronchodilators inhalers and inhaled corticosteroids purchases among asthma and COPD patients

BACKGROUND

Confounding reports of cardiovascular disease (CVD) with the use of Inhaled corticosteroids (ICS), long-acting beta-agonists, and muscarinic antagonists (LABA and LAMA) have been reported.

OBJECTIVE

To explore the relationship between the purchase of ICS, LABA and LAMA inhalers and the incidence of CVDs.

METHODS

This retrospective study included patients with COPD and/or asthma, aged ≥ 18 years, who purchased LABA, LAMA, and ICS inhalers alone or in combination between 2017 and 2019. We calculated the odds ratios (ORs) for CVD for patients who purchased at least one inhaler during the 12 months before the diagnosis and those without any purchase from the same inhaler group. We also analyzed the risk among asthma patients and COPD patients.

RESULTS

Of the 94,834-study population, 74,974 had asthma, 46,907 had COPD, and 27,047 had an asthma-COPD overlap. Average age was 57.9±19.7, and 44% were males. The most prominent effects of ICS were reduced risks for myocarditis (OR 0.35, 95%CI 0.14, 0.9), ischemic heart disease (IHD) (OR 0.45, 95%CI 0.41, 0.49), valvular disease (OR 0.47, 95%CI 0.39, 0.55) and hypertension (HTN) (OR 0.47, 95%CI 0.42, 0.52). LABA inhalers had a significantly lower risk for conduction disorders and arrhythmias (OR 0.71, 95%CI 0.55, 0.92), HTN (OR 0.76, 95%CI 0.63, 0.92), and cerebrovascular diseases (OR 0.83, 95%CI 0.74, 0.94). In comparison, patients with COPD had a significantly lower risk for heart failure (OR 0.62, 95%CI 0.48, 0.8). LAMA inhalers conferred a substantially lower risk of HTN (OR 0.66, 95%CI 0.57, 0.76), peripheral vascular diseases (OR 0.75, 95%CI 0.61, 0.92), IHD (OR 0.8, 95%CI 0.72, 0.89), and cerebrovascular disease (OR 0.85, 95%CI 0.78, 0.92).

CONCLUSION

ICS inhalers were associated with a significant reduction in the incidence of CVD, with lesser but significant effects observed among those using LABA and LAMA inhalers.

Overlap Syndrome (COPD and OSA): A Treatable Trait for Triple Treatment?

The coexistence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) in the same patient is referred to as overlap syndrome (OS). Patients with OS suffer more frequently from cardiovascular disease (CVD) and carry a higher risk of COPD-related exacerbations than patients with COPD alone, especially when OSA is left untreated. Based on recent evidence, triple therapy, namely inhaled corticosteroid/long-acting muscarinic antagonist/long-acting beta-agonist (ICS-LABA-LAMA), is a treatment strategy in COPD patients with a history of exacerbations and/or CVD comorbidity. While several studies have previously focused on the role of triple therapy in patients with COPD, none of these has examined the potential benefits of this treatment in patients with COPD and concomitant OSA. Moreover, it is unknown whether patients with OS should be treated with triple therapy starting from their initial assessment, since they represent a population at risk for future exacerbations, in comparison to patients with COPD alone. In this commentary, we discuss these issues and highlight the need for further studies regarding the role of triple therapy in outcomes for patients with OS.

Goals of chronic obstructive pulmonary disease management: a focused review for clinicians

PURPOSE OF REVIEW

The diagnosis of chronic obstructive pulmonary disease (COPD) encompasses heterogeneous pathophysiological mechanisms which can shape an individual patient's experience. This paper reviews available therapeutic options for the clinician intending to individualize care toward patient goals.

RECENT FINDINGS

The contemporary targeted interventions for COPD include the novel phosphodiesterase inhibitor ensifentrine, the interleukin-4 receptor (IL4R alpha subunit) antibody dupilumab, augmentation therapy for alpha-1 antitrypsin deficiency. Other interventions promoting physical and mental well being include re-envisioned pulmonary rehabilitation, self-management, targeting of comorbidities such as sarcopenia, and virtual health coaching interventions to expand patient access. Opioids did not relieve dyspnea and did not change total step count.

SUMMARY

Advances in precision therapy are complemented by the discovery of novel pathophysiology pathways and behavioral and rehabilitation interventions as a holistic view of COPD management emerges. The management of COPD continues to evolve with new tools including precision medicine and individualized care. Comorbidities remain important determinants of health, yet their prevalence and impact are underestimated.

Molecular Approaches to Treating Chronic Obstructive Pulmonary Disease: Current Perspectives and Future Directions

Chronic obstructive pulmonary disease (COPD) is a clinical syndrome that presents as airflow limitation with poor reversibility accompanied by dynamic hyperinflation of the lung. It is a complex disease with chronic inflammatory airway changes caused by exposure to noxious particles or gases, such as cigarette smoke. The disease involves persistent inflammation and oxidative stress, perpetuated by frequent exacerbations. The prevalence of COPD is on the rise, with the prediction that it will be the leading cause of morbidity and mortality over the next decade. Despite the global burden of COPD and its associated morbidity and mortality, treatment remains limited. Although the understanding of the pathogenesis of COPD has increased over the last two decades, molecular approaches to develop new therapies for the treatment of COPD have lagged. Here, we review the molecular approaches that have the potential for developing novel therapies for COPD.

Prospective Randomized Study on Switching Triple Inhaler Therapy in COPD from Multiple Inhaler Devices to a Single Inhaler Device in a Chinese Population

Background

Triple therapy with inhaled corticosteroids and dual bronchodilator therapy is recommended for chronic obstructive pulmonary disease (COPD) patients who have exacerbations and eosinophilia. It can be administered by single inhaler triple therapy (SITT) or by multiple inhaler triple therapy (MITT). There is a lack of evidence of the benefits of SITT over MITT in the Chinese population, especially on switching from existing MITT to SITT.

Methods

A total of 70 Chinese patients with COPD were recruited in this open-label, double-arm clinical trial to investigate the number of critical inhaler errors, the modified Medical Research Council (mMRC) dyspnea scale, the Medication Adherence Report Scale for Asthma (MARS-A) score, and a satisfaction score upon switching from MITT to SITT.

Results

The mean number of critical inhaler errors was 0.4±1.0 in the SITT group and 1.1±1.8 in the MITT group( p=0.038) at the first visit; and 0.2±0.6 in the SITT group and 0.8±1.1 in the MITT group (p=0.007) at the second visit. The mean change in MARS-A from baseline to first visit was +3.76±7.48 in the SITT group and -1.27±7.76 in the MITT group (p-value 0.008). A total of 22 (59.5%) and 8 (24.2%) of the patients in the SITT and the MITT group respectively, had an increase in MARS-A score from baseline to first visit, with an adjusted odds ratio of 6.23 (95% confidence interval=1.63-23.77, p=0.007), favoring SITT. There was no significant difference in the change in the mMRC dyspnea scale and the satisfaction score between the 2 groups.

Conclusion

Switching from MITT to SITT in Chinese COPD patients may have the benefits of having fewer critical inhaler errors and a higher MARS-A score.

High-risk adverse events in two types of single inhaler triple-therapy: a pharmacovigilance study based on the FAERS database

Objective

Single inhaler triple therapy is widely used in Chronic Obstructive Pulmonary Disease (COPD) and asthma. This research aimed to analyze adverse events (AEs) associated with Budesonide/Glycopyrronium/Formoterol Fumarate (BUD/GLY/FOR) and Fluticasone Furoate/Umeclidinium/Vilanterol (FF/UMEC/VI).

Methods

This is a cross-sectional study. BUD/GLY/FOR (2020Q3-2024Q3) and FF/UMEC/VI (2018Q1-2024Q3) report files were downloaded from the U.S. Food and Drug Administration's (FDA) Adverse Event Reporting System (FAERS) database. We use reporting odds ratio (ROR), proportional reporting ratio (PRR), and Bayesian confidence propagation neural network (BCPNN) for disproportionality analysis. The aim was to explore associations between drugs and preferred term (PT) and system organ classification (SOC) levels. We focused on exploring the top 10 PTs of each drug's BCPNN (IC) effect value and the PT of pneumonia.

Results

16,355 AEs in BUD/GLY/FOR and 39,110 AEs in FF/UMEC/VI were extracted. Device use issues, oropharyngeal and vocal problems, pneumonia, candida infections, and urinary retention were the standard PTs present in drug leaflets. The risk of device use issues was higher in BUD/GLY/FOR, whereas the risk of pneumonia and candida infection in FF/UMEC/ VI had higher risk. Outside of the drug leaflets, both drugs were associated with a higher risk of AEs in vascular disorders. BUD/GLY/FOR group had a higher risk of AEs in body height decreased and hypoacusis. Notably, this study found an association between the above PTs and drugs, and the causal relationship needs to be verified by further longitudinal studies.

Conclusion

Our study provides a preliminary exploration of the safety of clinical use of BUD/GLY/FOR and FF/UMEC/VI, and clinicians should be alert to potential adverse effects.

The Saudi Thoracic Society Evidence-based guidelines for the diagnosis and management of chronic obstructive pulmonary disease

The Saudi Thoracic Society (STS) developed an updated evidence-based guideline for diagnosing and managing chronic obstructive pulmonary disease (COPD) in Saudi Arabia. This guideline aims to provide a comprehensive and unbiased review of current evidence for assessing, diagnosing, and treating COPD. While epidemiological data on COPD in Saudi Arabia are limited, the STS panel believes that the prevalence is increasing due to rising rates of tobacco smoking. The key objectives of the guidelines are to facilitate accurate diagnosis of COPD, identify the risk for COPD exacerbations, and provide recommendations for relieving and reducing COPD symptoms in stable patients and during exacerbations. A unique aspect of this guideline is its simplified, practical approach to classifying patients into three classes based on symptom severity using the COPD Assessment Test and the risk of exacerbations and hospitalizations. The guideline provides the reader with an executive summary of recommended COPD treatments based on the best available evidence and also addresses other major aspects of COPD management and comorbidities. This guideline is primarily intended for use by internists and general practitioners in Saudi Arabia.

Is 'Cardiopulmonary' the New 'Cardiometabolic'? Making a Case for Systems Change in COPD

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) have a syndemic relationship with shared risk factors and complex interplay between genetic, environmental, socioeconomic, and pathophysiological mechanisms. CVD is among the most common comorbidities in patients with COPD and vice versa. Patients with COPD, irrespective of their disease severity, are at increased risk of CVD morbidity and mortality, driven in part by COPD exacerbations. Despite these known interrelationships, CVD is underestimated and undertreated in patients with COPD. Similarly, COPD is an independent risk-enhancing factor for adverse cardiovascular (CV) events, yet it is not incorporated into current CV risk assessment tools, leading to under-recognition and undertreatment. There is a pressing need for systems change in COPD management to move beyond symptom control towards a comprehensive cardiopulmonary disease paradigm with proactive prevention of exacerbations and adverse cardiopulmonary outcomes and mortality. However, there is a dearth of evidence defining optimal cardiopulmonary care pathways. Fortunately, there is a precedent to support systems-level change in the field of diabetes, which evolved from glycemic control to comprehensive multi-organ risk assessment and management. Key elements included integrated multidisciplinary care, intensive risk factor management, coordination between primary and specialist care, care pathways and protocols, education and self management, and disease-modifying therapies. This commentary article draws parallels between the cardiometabolic and cardiopulmonary paradigms and makes a case for systems change towards multidisciplinary, integrated cardiopulmonary care, using the evolution in diabetes care as a potential framework.

Exacerbation History and Risk of Myocardial Infarction and Pulmonary Embolism in COPD

BACKGROUND

Acute exacerbations (AEs) of COPD are increasingly recognized as episodes of heightened risk of cardiovascular events. It is not known whether exacerbation history is differentially associated with future myocardial infarction (MI) or pulmonary embolism (PE).

RESEARCH QUESTION

Is the number and severity of AEs of COPD associated with increased risk of MI or PE in a real-life cohort of patients with COPD?

STUDY DESIGN AND METHODS

We identified a cohort of 66,422 patients (≥ 30 years of age) with a primary diagnosis of COPD in the Swedish National Airway Register from January 2014 to June 2022, with complete data on lung function. Patients were classified by moderate (prescription of oral corticosteroids) and severe (hospitalization) exacerbations the year before index date and were followed until December 2022 for hospitalization or death from MI or PE, corresponding to > 265,000 patient-years, with a maximum follow-up time of 9 years. Competing risk regression, according to the Fine-Gray model, was used to calculate subdistribution hazard ratios with 95% CIs.

RESULTS

Compared with no AEs of COPD in the baseline period, AE of COPD number and severity were associated with increased long-term risk of both MI and PE in a gradual fashion, ranging from a subdistribution hazard ratio of 1.10 (95% CI, 0.97-1.24) and 1.33 (95% CI, 1.11-1.60), respectively, for one moderate exacerbation, to 1.82 (95% CI, 1.36-2.44) and 2.62 (95% CI, 1.77-3.89), respectively, for two or more severe exacerbations. In a time-restricted follow-up sensitivity analysis, the associations were stronger during the first year of follow-up and diminished over time.

INTERPRETATION

The risk of MI and PE increased with the frequency and severity of AEs of COPD in this large, real-life cohort of patients with COPD.

Update of prognosis and characteristics of chronic obstructive pulmonary disease in a real-world setting: a 5-year follow-up analysis of a multi-institutional registry

BACKGROUND

We conducted a prospective observational study to elucidate the long-term prognosis and management of chronic obstructive pulmonary disease (COPD) in clinical practice in Japan in the mid-2010s.

METHODS

This prospective cohort study included 29 facilities. Data from 427 patients clinically diagnosed with COPD, enrolled between September 2013 and April 2016, were analyzed. Interstitial pneumonia was excluded through a central multidisciplinary discussion. Follow-up data were collected for up to 5 years after patient registration.

RESULTS

At the time of registration, 53 patients clinically diagnosed with COPD did not have airflow limitation (AFL). In the cohort with AFL (n = 374), 232 patients completed a 5-year follow-up, while 49 patients died during the 1576.6 person-years of observation. The mean age was 71.7 years with an overall 5-year survival rate of 85.4%. Stratified by % forced expiratory volume in one second (FEV1), survival rates were 93.6% in the mild and moderate AFL group, 82.5% in the severe AFL group, and 66.1% in the very severe AFL group. The prognosis of the subpopulation without AFL was poor with a 5-year survival of 81.6%. This subpopulation exhibited respiratory symptoms, low vital capacity and total lung capacity, and emphysematous changes.

CONCLUSIONS

Our study presents the 5-year survival and real-world clinical practice scenario of a prospective cohort of patients clinically diagnosed with COPD in Japan in the mid-2010s. The survival rates of our cohort were numerically better than the Japanese cohort in the 1990s, regardless of the high median age of this cohort. Overall, 12.4% of the patients in this cohort with no AFL at registration exhibited respiratory symptoms and distinct spirometric patterns, and had a poor prognosis.

Inhaled Corticosteroids Particle Size and Risk of Hospitalization Due to Exacerbations and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease. A Nationwide Cohort Study

Background

Extra-fine particle inhaled corticosteroids (ICS) improve peripheral airway distribution, but their effect on risk of exacerbations and all-cause mortality in patients with chronic obstructive pulmonary disease (COPD) is unclear.

Methods

This observational cohort study compares patients with COPD who received extra-fine particle ICS to those who received standard particle size ICS from 2010 to 2017 while followed in outpatient clinics. The primary outcome was the time to a COPD exacerbation that required hospitalization, with all-cause mortality as a secondary outcome. Data were analyzed using an adjusted Cox proportional hazards model and a competing risk analysis. Two predefined subgroup analyses of patients treated with pressurised metered dose inhalers (pMDIs) and patients with a previous exacerbation history, was carried out. Lastly, we created a propensity score matched cohort as a sensitivity analysis.

Results

Of the 40,489 patients included, 38,802 (95.8%) received stand particle size ICS and 1,687 (4.2%) received extra-fine particle ICS. In total 7,058 were hospitalized with a COPD exacerbation, and 4,346 died. No significant protective effect of extra-fine particle ICS against hospitalization due to COPD exacerbations (HR 0.93, 95% CI 0.82-1.05, p=0.23) or all-cause mortality (HR 1.00, 95% CI 0.85-1.17, p=0.99) was found when compared to standard particle size ICS. However, in the subgroup analysis of patients treated with pMDIs, extra-fine particle ICS was associated with reduction in risk of exacerbations (HR 0.72, 95% CI 0.63-0.82, p<0.001) and all-cause mortality (HR 0.72, 95% CI 0.61-0.86, p<0.001).

Conclusion

The administration of extra-fine particle ICS was not associated with reduced risk of exacerbations or all-cause mortality in our primary analysis. A subgroup consisting of patients treated with pMDIs suggested potential protective benefits.

Reducing the risk of death - a possible outcome in COPD patients

INTRODUCTION

COPD is a leading cause of global mortality, particularly under-recognized and under-diagnosed. In 2020, it was the sixth leading cause of death in the US and has contributed to 4.72% of all-cause mortality (ACM) according to the Global Burden of Disease Study 2017. Factors influencing COPD-related mortality include smoking, aging populations, comorbidities, sarcopenia, physical capacity, and lack of effective treatments.

AREAS COVERED

This review discusses various factors influencing COPD-related mortality and analyzes observational studies and pivotal RCTs evaluating the impact of different therapies on ACM.

EXPERT OPINION

COPD significantly impacts ACM, necessitating effective management strategies. Smoking cessation is crucial in reducing mortality risk. Exacerbation management and comorbidity treatment are essential to improve patient outcomes. Various therapeutic interventions, such as smoking cessation, vaccination, long-term oxygen therapy, and lung volume reduction surgery, have shown benefits in reducing mortality. Pharmacotherapies might reduce the risk of mortality, although the current scientific evidences remain inconclusive. Advances in pharmacological interventions, tailored treatment plans, and physical activity programs are vital. More robust and long-term studies, focusing on real-world data and addressing biases in treatment allocation, are needed to conclusively determine the efficacy of different therapies in reducing ACM in COPD patients.

An Italian Delphi Consensus on the Triple inhalation Therapy in Chronic Obstructive Pulmonary Disease

BACKGROUND

The management of chronic obstructive pulmonary disease (COPD) lacks standardization due to the diverse clinical presentation, comorbidities, and limited acceptance of recommended approaches by physicians. To address this, a multicenter study was conducted among Italian respiratory physicians to assess consensus on COPD management and pharmacological treatment.

METHODS

The study employed the Delphi process using the Estimate-Talk-Estimate method, involving a scientific board and expert panel. During a 6-month period, the scientific board conducted the first Delphi round and identified 11 broad areas of COPD management to be evaluated while the second Delphi round translated all 11 items into statements. The statements were subsequently presented to the expert panel for independent rating on a nine-point scale. Consensus was considered achieved if the median score was 7 or higher. Consistently high levels of consensus were observed in the first rating, allowing the scientific board to finalize the statements without requiring further rounds.

RESULTS

Topics generating substantial discussion included the pre-COPD phase, patient-reported outcomes, direct escalation from a single bronchodilator to triple therapy, and the role of adverse events, particularly pneumonia, in guiding triple therapy prescriptions. Notably, these topics exhibited higher standard deviations, indicating greater variation in expert opinions.

CONCLUSIONS

The study emphasized the significance that Italian pulmonologists attribute to managing mortality, tailoring treatments, and addressing cardiovascular comorbidities in COPD patients. While unanimous consensus was not achieved for all statements, the results provide valuable insights to inform clinical decision-making among physicians and contribute to a better understanding of COPD management practices in Italy.

A Pilot Study on Proteomic Predictors of Mortality in Stable COPD

Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of global mortality. Despite clinical predictors (age, severity, comorbidities, etc.) being established, proteomics offers comprehensive biological profiling to obtain deeper insights into COPD pathophysiology and survival prognoses. This pilot study aimed to identify proteomic footprints that could be potentially useful in predicting mortality in stable COPD patients. Plasma samples from 40 patients were subjected to both blind (liquid chromatography-mass spectrometry) and hypothesis-driven (multiplex immunoassays) proteomic analyses supported by artificial intelligence (AI) before a 4-year clinical follow-up. Among the 34 patients whose survival status was confirmed (mean age 69 ± 9 years, 29.5% women, FEV1 42 ± 15.3% ref.), 32% were dead in the fourth year. The analysis identified 363 proteins/peptides, with 31 showing significant differences between the survivors and non-survivors. These proteins predominantly belonged to different aspects of the immune response (12 proteins), hemostasis (9), and proinflammatory cytokines (5). The predictive modeling achieved excellent accuracy for mortality (90%) but a weaker performance for days of survival (Q2 0.18), improving mildly with AI-mediated blind selection of proteins (accuracy of 95%, Q2 of 0.52). Further stratification by protein groups highlighted the predictive value for mortality of either hemostasis or pro-inflammatory markers alone (accuracies of 95 and 89%, respectively). Therefore, stable COPD patients' proteomic footprints can effectively forecast 4-year mortality, emphasizing the role of inflammatory, immune, and cardiovascular events. Future applications may enhance the prognostic precision and guide preventive interventions.

Breaking down barriers to COPD management in primary care: applying the updated 2023 Canadian Thoracic Society guideline for pharmacotherapy

Chronic obstructive pulmonary disease (COPD) is a highly prevalent yet under-recognized and sub-optimally managed disease that is associated with substantial morbidity and mortality. Primary care providers (PCPs) are at the frontlines of COPD management, and they play a critical role across the full spectrum of the COPD patient journey from initial recognition and diagnosis to treatment optimization and referral to specialty care. The Canadian Thoracic Society (CTS) recently updated their guideline on pharmacotherapy in patients with stable COPD, and there are several key changes that have a direct impact on COPD management in the primary care setting. Notably, it is the first guideline to formally make recommendations on mortality reduction in COPD, which elevates this disease to the same league as other chronic diseases that are commonly managed in primary care and where optimized pharmacotherapy can reduce all-cause mortality. It also recommends earlier and more aggressive initial maintenance inhaler therapy across all severities of COPD, and preferentially favors the use of single inhaler therapies over multiple inhaler regimens. This review summarizes some of the key guideline changes and offers practical tips on how to implement the new recommendations in primary care. It also addresses other barriers to optimal COPD management in the primary care setting that are not addressed by the guideline update and suggests strategies on how they could be overcome.

Adherence to single inhaler triple therapy and digital inhalers in Chronic Obstructive Pulmonary Disease: a literature review and protocol for a randomized controlled trial (TRICOLON study)

BACKGROUND

Medication non-adherence is a significant problem in patients with Chronic Obstructive Pulmonary Disease (COPD). Efforts to address this issue are receiving increased attention. Simplifying treatment by prescribing single-inhaler triple therapy (SITT) as an alternative to multi-inhaler triple therapy (MITT) or with smart inhalers are often considered potential solutions. However, the actual impact of these innovations on adherence and clinical outcomes is unclear.

METHODS

To address this knowledge gap we first conducted a literature review focusing on two research questions: 1) the difference in adherence between SITT and MITT users in COPD, and 2) the effect of smart inhalers on adherence in COPD. Separate searches were conducted in PubMed and two authors independently assessed the articles. In addition, we present a protocol for a study to acquire knowledge for the gaps identified.

RESULTS

To address the first research question, 8 trials were selected for further review. All trials were observational, i.e. randomized controlled trials were lacking. Seven of these trials showed higher adherence and/or persistence in patients on SITT compared with patients on MITT. In addition, four studies showed a positive effect of SITT on various clinical outcomes. For the second research question, 11 trials were selected for review. While most of the studies showed a positive effect of smart inhalers on adherence, there was considerable variation in the results regarding their effect on other clinical outcomes. The TRICOLON (TRIple therapy COnvenience by the use of one or multipLe Inhalers and digital support in ChrONic Obstructive Pulmonary Disease) trial aims to improve understanding regarding the effectiveness of SITT and smart inhalers in enhancing adherence. This open-label, randomized, multi-center study will enroll COPD patients requiring triple therapy at ten participating hospitals. In total, 300 patients will be randomized into three groups: 1) MITT; 2) SITT; 3) SITT with digital support through a smart inhaler and an e-health platform. The follow-up period will be one year, during which three methods of measuring adherence will be used: smart inhaler data, self-reported data using the Test of Adherence to Inhalers (TAI) questionnaire, and drug analysis in scalp hair samples. Finally, differences in clinical outcomes between the study groups will be compared.

DISCUSSION

Our review suggests promising results concerning the effect of SITT, as opposed to MITT, and smart inhalers on adherence. However, the quality of evidence is limited due to the absence of randomized controlled trials and/or the short duration of follow-up in many studies. Moreover, its impact on clinical outcomes shows considerable variation. The TRICOLON trial aims to provide solid data on these frequently mentioned solutions to non-adherence in COPD. Collecting data in a well-designed randomized controlled trial is challenging, but the design of this trial addresses both the usefulness of SITT and smart inhalers while ensuring minimal interference in participants' daily lives.

TRIAL REGISTRATION

NCT05495698 (Clinicaltrials.gov), registered at 08-08-2022. Protocol version: version 5, date 27-02-2023.

Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review

Chronic obstructive pulmonary disease (COPD) constitutes a major global health burden and is the third leading cause of death worldwide. A high proportion of patients with COPD have cardiovascular disease, but there is also evidence that COPD is a risk factor for adverse outcomes in cardiovascular disease. Patients with COPD frequently die of respiratory and cardiovascular causes, yet the identification and management of cardiopulmonary risk remain suboptimal owing to limited awareness and clinical intervention. Acute exacerbations punctuate the progression of COPD in many patients, reducing lung function and increasing the risk of subsequent exacerbations and cardiovascular events that may lead to early death. This narrative review defines and summarises the principles of COPD-associated cardiopulmonary risk, and examines respiratory interventions currently available to modify this risk, as well as providing expert opinion on future approaches to addressing cardiopulmonary risk.

Mortality of patients with COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is the third most common cause of death worldwide and 24% of the patients die within 5 years of diagnosis.

AREAS COVERED

The epidemiology of mortality and the interventions that reduce it are reviewed. The increasing global deaths reflect increases in population sizes, increasing life expectancy and reductions in other causes of death. Strategies to reduce mortality aim to prevent the development of COPD and improve the survival of individuals. Historic changes in mortality give insights: improvements in living conditions and nutrition, and later improvements in air quality led to a large fall in mortality in the early 20th century. The smoking epidemic temporarily reversed this trend.Older age, worse lung function and exacerbations are risk factors for death. Single inhaler triple therapy; smoking cessation; pulmonary rehabilitation; oxygen therapy; noninvasive ventilation; and surgery reduce mortality in selected patients.

EXPERT OPINION

The importance of addressing the global burden of mortality from COPD must be recognized. Steps must be taken to reduce it, by reducing exposure to risk factors, assessing individual patients' risk of death and using treatments that reduce the risk of death. Mortality rates are falling in countries that have adopted a comprehensive approach to COPD prevention and treatment.

Mortality prevention as the centre of COPD management

COPD is a major healthcare problem and cause of mortality worldwide. COPD patients at increased mortality risk are those who are more symptomatic, have lower lung function and lower diffusing capacity of the lung for carbon monoxide, decreased exercise capacity, belong to the emphysematous phenotype and those who have concomitant bronchiectasis. Mortality risk seems to be greater in patients who experience COPD exacerbations and in those who suffer from concomitant cardiovascular and/or metabolic diseases. To predict the risk of death in COPD patients, several composite scores have been created using different parameters. In previous years, large studies (also called mega-trials) have evaluated the efficacy of different therapies on COPD mortality, but until recently only nonpharmaceutical interventions have proven to be effective. However, recent studies on fixed combinations of triple therapy (long-acting β-agonists, long-acting muscarinic antagonists and inhaled corticosteroids) have provided encouraging results, showing for the first time a reduction in mortality compared to dual therapies. The aim of the present review is to summarise available data regarding mortality risk in COPD patients and to describe pharmacological therapies that have shown effectiveness in reducing mortality.

[Take-home messages from the 2nd COPD 2023 Biennial of the French Society of Respiratory Diseases. Placing the patient at the center of the care pathway]

INTRODUCTION

The second COPD Biennial organized by the COPD working group of the French Society of Respiratory Diseases took place in Paris (Cochin) on 13th December 2023.

STATE OF THE ART

Major trends in 2023 were discussed; they encompassed concepts, definitions, biologics, care pathways, pulmonary rehabilitation and complex situations entailed by respiratory infections, cardiovascular comorbidities and pulmonary hypertension, and modalities of oxygen therapy and ventilation.

PERSPECTIVES

The different talks underlined major changes in COPD including the concepts of pre-COPD, etiotypes, health trajectories and new definitions of exacerbation. Recent results in biologics for COPD open the door to new pharmacological options. Assessment of current care pathways in France highlighted some causes for concern. For example, pulmonary rehabilitation is a key but insufficiently practiced element. Respiratory infections require careful assessment and treatments. Diagnosis and treatment of cardiovascular comorbidities and pulmonary hypertension are of paramount importance. As of late, oxygen therapy and ventilation modalities have evolved, and are beginning to afford more personalized options.

CONCLUSIONS

As regards COPD, a personalized approach is crucial, placing the patient at the center of the care pathway and facilitating coordination between healthcare providers.

Immune Dysregulation in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a disease whose incidence increase with age and is characterised by chronic inflammation and significant immune dysregulation. Inhalation of toxic substances cause oxidative stress in the lung tissue as well as airway inflammation, under the recruitment of chemokines, immune cells gathered and are activated to play a defensive role. However, persistent inflammation damages the immune system and leads to immune dysregulation, which is mainly manifested in the reduction of the body's immune response to antigens, and immune cells function are impaired, further destroy the respiratory defensive system, leading to recurrent lower respiratory infections and progressive exacerbation of the disease, thus immune dysregulation play an important role in the pathogenesis of COPD. This review summarizes the changes of innate and adaptive immune-related cells during the pathogenesis of COPD, aiming to control COPD airway inflammation and improve lung tissue remodelling by regulating immune dysregulation, for further reducing the risk of COPD progression and opening new avenues of therapeutic intervention in COPD.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Multidisciplinary Management of Patients With Chronic Obstructive Pulmonary Disease and Cardiovascular Disease

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently coexist, increasing the prevalence of both entities and impacting on symptoms and prognosis. CVD should be suspected in patients with COPD who have high/very high risk scores on validated scales, frequent exacerbations, precordial pain, disproportionate dyspnea, or palpitations. They should be referred to cardiology if they have palpitations of unknown cause or angina pain. COPD should be suspected in patients with CVD if they have recurrent bronchitis, cough and expectoration, or disproportionate dyspnea. They should be referred to a pulmonologist if they have rhonchi or wheezing, air trapping, emphysema, or signs of chronic bronchitis. Treatment of COPD in cardiovascular patients should include long-acting muscarinic receptor antagonists (LAMA) or long-acting beta-agonists (LABA) in low-risk or high-risk non-exacerbators, and LAMA/LABA/inhaled corticosteroids in exacerbators who are not controlled with bronchodilators. Cardioselective beta-blockers should be favored in patients with CVD, the long-term need for amiodarone should be assessed, and antiplatelet drugs should be maintained if indicated.

Inhaled Corticosteroids in Subjects with Chronic Obstructive Pulmonary Disease: An Old, Unfinished History

Chronic obstructive pulmonary disease (COPD) is one of the major causes of disability and death. Maintenance use of inhaled bronchodilator(s) is the cornerstone of COPD pharmacological therapy, but inhaled corticosteroids (ICSs) are also commonly used. This narrative paper reviews the role of ICSs as maintenance treatment in combination with bronchodilators, usually in a single inhaler, in stable COPD subjects. The guidelines strongly recommend the addition of an ICS in COPD subjects with a history of concomitant asthma or as a step-up on the top of dual bronchodilators in the presence of hospitalization for exacerbation or at least two moderate exacerbations per year plus high blood eosinophil counts (≥300/mcl). This indication would only involve some COPD subjects. In contrast, in real life, triple inhaled therapy is largely used in COPD, independently of symptoms and in the presence of exacerbations. We will discuss the results of recent randomized controlled trials that found reduced all-cause mortality with triple inhaled therapy compared with dual inhaled long-acting bronchodilator therapy. ICS use is frequently associated with common local adverse events, such as dysphonia, oral candidiasis, and increased risk of pneumonia. Other side effects, such as systemic toxicity and unfavorable changes in the lung microbiome, are suspected mainly at higher doses of ICS in elderly COPD subjects with comorbidities, even if not fully demonstrated. We conclude that, contrary to real life, the use of ICS should be carefully evaluated in stable COPD patients.

National Development in the Use of Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease: Repeated Cross-Sectional Studies from 1998 to 2018

Recommendations for the treatment of chronic obstructive pulmonary disease (COPD) have shifted towards a more restrictive use of inhaled corticosteroids (ICS). We aimed to identify the nationwide development over time in the use of ICS treatment in COPD. We conducted a register-based repeated cross-sectional study using Danish nationwide registers. On a yearly basis from 1998 to 2018, we included all patients in Denmark ≥ 40 years of age with an ICD-10 diagnosis of COPD (J44). Accumulated ICS use was calculated for each year based on redeemed prescriptions. Patients were divided into the following groups: No ICS, low-dose ICS, medium-dose ICS, or high-dose ICS. From 1998 to 2018, the yearly proportion of patients without ICS treatment increased (from 50.6% to 57.6%), the proportion of patients on low-dose ICS treatment increased (from 11.3% to 14.9%), and the proportion of patients on high-dose ICS treatment decreased (from 17.0% to 9.4%). We demonstrated a national reduction in the use of ICS treatment in COPD from 1998 to 2018, with an increase in the proportion of patients without ICS and on low-dose ICS treatment and a decrease in the proportion of patients on high-dose ICS treatment.

Risk of Death and Cardiovascular Events Following an Exacerbation of COPD: The EXACOS-CV US Study

Purpose

This study estimated the magnitude and duration of risk of cardiovascular events and mortality following acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and whether risks varied by number and severity of exacerbation in a commercially insured population in the United States.

Methods

This was a retrospective cohort study of newly diagnosed COPD patients ≥40 years old in the Healthcare Integrated Research Database from 2012 to 2019. Patients experiencing exacerbations comprised the "exacerbation cohort". Moderate exacerbations were outpatient visits with contemporaneous antibiotic or glucocorticoid administration; severe exacerbations were emergency department visits or hospitalizations for AECOPD. Follow-up started on the exacerbation date. Distribution of time between diagnosis and first exacerbation was used to assign index dates to the "unexposed" cohort. Cox proportional hazards models estimated risks of a cardiovascular event or death following an exacerbation adjusted for medical and prescription history and stratified by follow-up time, type of cardiovascular event, exacerbation severity, and rank of exacerbation (first, second, or third).

Results

Among 435,925 patients, 170,236 experienced ≥1 exacerbation. Risk of death was increased for 2 years following an exacerbation and was highest during the first 30 days (any exacerbation hazard ratio (HR)=1.79, 95% CI=1.58-2.04; moderate HR=1.22, 95% CI=1.04-1.43; severe HR=5.09, 95% CI=4.30-6.03). Risks of cardiovascular events were increased for 1 year following an AECOPD and highest in the first 30-days (any exacerbation HR=1.34, 95% CI=1.23-1.46; moderate HR=1.23 (95% CI 1.12-1.35); severe HR=1.93 (95% CI=1.67-2.22)). Each subsequent AECOPD was associated with incrementally higher rates of both death and cardiovascular events.

Conclusion

Risk of death and cardiovascular events was greatest in the first 30 days and rose with subsequent exacerbations. Risks were elevated for 1-2 years following moderate and severe exacerbations, highlighting a sustained increased cardiopulmonary risk associated with exacerbations.

Eligibility of patients with chronic obstructive pulmonary disease for inclusion in randomised control trials investigating triple therapy: a study using routinely collected data

BACKGROUND

Randomised control trials (RCTs) with strict eligibility criteria can lead to trial populations not commonly seen in clinical practice. We described the proportion of people with chronic obstructive pulmonary disease (COPD) in England eligible for RCTs investigating treatment with triple therapy.

METHODS

MEDLINE and Clinicaltrials.gov were searched for RCTs investigating triple therapy and eligibility criteria for each trial were extracted. Using routinely collected primary care data from Clinical Practice Research Datalink Aurum linked with Hospital Episode Statistics, we defined a population of COPD patients registered at a general practice in England, who were ≥ 40 years old, and had a history of smoking. Inclusion date was January 1, 2020. Patients who died earlier or left the general practice were excluded. Eligibility criteria for each RCT was applied to the population of COPD patients and the proportion of patients meeting each trial eligibility criteria were described.

RESULTS

26 RCTs investigating triple therapy were identified from the literature. The most common eligibility criteria were post-bronchodilator FEV1% predicted 30-80%, ≥ 2 moderate/≥ 1 severe exacerbations 12-months prior, no moderate exacerbations one-month prior and no severe exacerbations three-months prior, and the use of maintenance therapy or ICS use prior to inclusion. After applying each RCT eligibility criteria to our population of 79,810 COPD patients, a median of 11.2% [interquartile range (IQR) 1.8-17.4] of patients met eligibility criteria. The most discriminatory criteria included the presence exacerbations of COPD and previous COPD related medication use with a median of 67.6% (IQR 8.5-73.4) and 63% (IQR 69.3-38.4) of COPD patients not meeting these criteria, respectively.

CONCLUSION

Data from these RCTs may not be generalisable to the wider population of people with COPD seen in everyday clinical practice and real-world evidence studies are needed to supplement trials to understand effectiveness in all people with COPD.

Real-World Effectiveness of Fluticasone Furoate/Umeclidinium/Vilanterol Once-Daily Single-Inhaler Triple Therapy for Symptomatic COPD: The ELLITHE Non-Interventional Trial

Purpose

Real-life effectiveness data on once-daily single-inhaler triple therapy (odSITT) with the inhaled corticosteroid fluticasone furoate (FF), the long-acting muscarinic antagonist umeclidinium (UMEC), and the long-acting β2-agonist vilanterol (VI) in patients with chronic obstructive pulmonary disease (COPD) are important to complement evidence from well-controlled randomized clinical trials. Effectiveness of odSITT was quantified by assessing health status and symptoms in usual care.

Patients and Methods

ELLITHE was a single-country (Germany), multicenter, open-label, non-interventional effectiveness study between 2020 and 2022, evaluating the effect of treatment initiation with FF/UMEC/VI 100/62.5/25 µg once-daily via the ELLIPTA inhaler on improvements in clinical outcomes versus baseline in COPD patients. The primary endpoint was the change in the total COPD Assessment Test (CAT) score between baseline and month 12. Key secondary endpoints included change in CAT score over time, occurrence of exacerbations until month 12, changes in forced expiratory volume in one second (FEV1), inhaler adherence, and safety.

Results

Nine hundred and six patients were included (age 66.6 years, 55.6% male, mean FEV1 52.6% of predicted, mean CAT 21.5 units, 1.4 exacerbations/year pre-study). About 63.9% of patients were escalated from dual therapies, and 18% were switched from multiple-inhaler triple therapies. Reductions in CAT score at month 12 were statistically significant and above the threshold of clinical importance (-2.6 units; p < 0.0001). CAT score also improved at interim visits. CAT improvements were more pronounced in patients with high baseline scores and better inhaler adherence. Exacerbations during follow-up were rare (0.2 events/year) compared to pre-study (1.4 events/year). FEV1 was improved by 93 mL (p < 0.0001). No new safety effects were observed.

Conclusion

In usual care, treatment with odSITT resulted in significant and clinically relevant improvements of CAT score and FEV1 in COPD patients, regardless of the occurrence of exacerbations. These findings challenge the current guideline recommendations for SITT only in patients experiencing exacerbations.

Asthma and COPD: A Focus on β-Agonists - Past, Present and Future

Asthma has been recognised as a respiratory disorder for millennia and the focus of targeted drug development for the last 120 years. Asthma is one of the most common chronic non-communicable diseases worldwide. Chronic obstructive pulmonary disease (COPD), a leading cause of morbidity and mortality worldwide, is caused by exposure to tobacco smoke and other noxious particles and exerts a substantial economic and social burden. This chapter reviews the development of the treatments of asthma and COPD particularly focussing on the β-agonists, from the isolation of adrenaline, through the development of generations of short- and long-acting β-agonists. It reviews asthma death epidemics, considers the intrinsic efficacy of clinical compounds, and charts the improvement in selectivity and duration of action that has led to our current medications. Important β2-agonist compounds no longer used are considered, including some with additional properties, and how the different pharmacological properties of current β2-agonists underpin their different places in treatment guidelines. Finally, it concludes with a look forward to future developments that could improve the β-agonists still further, including extending their availability to areas of the world with less readily accessible healthcare.

How inhaled corticosteroids target inflammation in COPD

Inhaled corticosteroids (ICS) are the most commonly used anti-inflammatory drugs for the treatment of COPD. COPD has been previously described as a "corticosteroid-resistant" condition, but current clinical trial evidence shows that selected COPD patients, namely those with increased exacerbation risk plus higher blood eosinophil count (BEC), can benefit from ICS treatment. This review describes the components of inflammation modulated by ICS in COPD and the reasons for the variation in response to ICS between individuals. There are corticosteroid-insensitive inflammatory pathways in COPD, such as bacteria-induced macrophage interleukin-8 production and resultant neutrophil recruitment, but also corticosteroid-sensitive pathways including the reduction of type 2 markers and mast cell numbers. The review also describes the mechanisms whereby ICS can skew the lung microbiome, with reduced diversity and increased relative abundance, towards an excess of proteobacteria. BEC is a biomarker used to enable the selective use of ICS in COPD, but the clinical outcome in an individual is decided by a complex interacting network involving the microbiome and airway inflammation.