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Melani AS, Croce S, Fabbri G, Messina M, Bargagli E. Inhaled Corticosteroids in Subjects with Chronic Obstructive Pulmonary Disease: An Old, Unfinished History. Biomolecules 2024; 14:195. [PMID: 38397432 PMCID: PMC10887366 DOI: 10.3390/biom14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the major causes of disability and death. Maintenance use of inhaled bronchodilator(s) is the cornerstone of COPD pharmacological therapy, but inhaled corticosteroids (ICSs) are also commonly used. This narrative paper reviews the role of ICSs as maintenance treatment in combination with bronchodilators, usually in a single inhaler, in stable COPD subjects. The guidelines strongly recommend the addition of an ICS in COPD subjects with a history of concomitant asthma or as a step-up on the top of dual bronchodilators in the presence of hospitalization for exacerbation or at least two moderate exacerbations per year plus high blood eosinophil counts (≥300/mcl). This indication would only involve some COPD subjects. In contrast, in real life, triple inhaled therapy is largely used in COPD, independently of symptoms and in the presence of exacerbations. We will discuss the results of recent randomized controlled trials that found reduced all-cause mortality with triple inhaled therapy compared with dual inhaled long-acting bronchodilator therapy. ICS use is frequently associated with common local adverse events, such as dysphonia, oral candidiasis, and increased risk of pneumonia. Other side effects, such as systemic toxicity and unfavorable changes in the lung microbiome, are suspected mainly at higher doses of ICS in elderly COPD subjects with comorbidities, even if not fully demonstrated. We conclude that, contrary to real life, the use of ICS should be carefully evaluated in stable COPD patients.
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Affiliation(s)
- Andrea S. Melani
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (S.C.); (G.F.); (M.M.); (E.B.)
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2
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Calle Rubio M, Miravitlles M, López-Campos JL, Alcázar Navarrete B, Soler Cataluña JJ, Fuentes Ferrer ME, Rodríguez Hermosa JL. Inhaled Maintenance Therapy in the Follow-Up of COPD in Outpatient Respiratory Clinics. Factors Related to Inhaled Corticosteroid Use. EPOCONSUL 2021 Audit. Arch Bronconeumol 2023; 59:725-735. [PMID: 37563018 DOI: 10.1016/j.arbres.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE The aim of this analysis was to describe the patterns of inhaled maintenance therapy according to risk level and to explore the determinants associated with the decision to prescribe inhaled corticosteroids (ICS) in addition to bronchodilator therapy according to risk level as strategy in the follow-up of COPD in daily clinical practice. METHODS EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to patients with a diagnosis of chronic obstructive pulmonary disease (COPD) in respiratory clinics in Spain with prospective recruitment between April 15, 2021 and January 31, 2022. RESULTS 4225 patients from 45 hospitals in Spain were audited. Risk levels were analyzed in 2678 patients. 74.5% of patients were classified as high risk and 25.5% as low risk according to GesEPOC criteria. Factors associated with the prescription of ICS in low-risk COPD were symptoms suggestive of asthma [OR: 6.70 (3.14-14.29), p<0.001], peripheral blood eosinophilia>300mm3 [OR: 2.16 (1.10-4.24), p=0.025], and having a predicted FEV1%<80% [OR: 2.17 (1.15-4.08), p=0.016]. In high-risk COPD, factors associated with triple therapy versus dual bronchodilator therapy were a mMRC dyspnea score of ≥2 [OR: 1.97 (1.41-2.75), p<0.001], symptoms suggestive of asthma [OR: 6.70 (3.14-14.29), p<0.001], and a predicted FEV1%<50% [OR: 3.09 (1.29-7.41), p<0.011]. CONCLUSIONS Inhaled therapy in the follow-up of COPD does not always conform to the current guidelines. Few changes in inhaled therapy are made at follow-up visits. The use of ICS is common in COPD patients who meet low-risk criteria in their follow-up and triple therapy in high-risk COPD patients is used as an escalation strategy in patients with high clinical impact. However, a history of exacerbations and eosinophil count in peripheral blood were not factors predicting triple therapy.
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Affiliation(s)
- Myriam Calle Rubio
- Pulmonology Department, Hospital Clínico San Carlos, Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Marc Miravitlles
- Pulmonology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - José Luis López-Campos
- Respiratory Disease Medical-Surgical Unit, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Manuel E Fuentes Ferrer
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Juan Luis Rodríguez Hermosa
- Pulmonology Department, Hospital Clínico San Carlos, Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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Anaev EK. [Eosinophilic chronic obstructive pulmonary disease: A review]. TERAPEVT ARKH 2023; 95:696-700. [PMID: 38158908 DOI: 10.26442/00403660.2023.08.202316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Indexed: 01/03/2024]
Abstract
Over the past decades, chronic obstructive pulmonary disease (COPD) has become a major public health problem due to increasing morbidity and mortality. COPD is characterized by airflow limitation due to inflammation of the bronchial tree and remodeling of the small airways. In 20-40% of patients with COPD, eosinophilic inflammation of the airways is observed, as in bronchial asthma. Eosinophilic COPD has recently been shown to be a distinct disease and is associated with more pronounced airway remodeling. Although the role of eosinophils in the pathogenesis of COPD is not fully understood, the level of eosinophils can be used in the prognosis and administration of corticosteroids, and their effectiveness is higher in eosinophilia. Currently, monoclonal antibodies directed against interleukins (IL-5, IL-4 and IL-13) or their receptors are being tested in the T2 endotype of COPD. This review focuses on the mechanisms of eosinophilia in COPD, the use of blood and sputum eosinophils as a biomarker, and the advisability of using monoclonal antibodies in the treatment of eosinophilic COPD.
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Affiliation(s)
- E K Anaev
- Pirogov Russian National Research Medical University
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Quint JK, Ariel A, Barnes PJ. Rational use of inhaled corticosteroids for the treatment of COPD. NPJ Prim Care Respir Med 2023; 33:27. [PMID: 37488104 PMCID: PMC10366209 DOI: 10.1038/s41533-023-00347-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/04/2023] [Indexed: 07/26/2023] Open
Abstract
Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.
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Affiliation(s)
- Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK.
| | - Amnon Ariel
- Lung Unit, Emek Medical Center, Afula, Israel
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
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Buhl R, Dreher M, Mattiucci-Guehlke M, Emerson-Stadler R, Eckhardt S, Taube C, Vogelmeier CF. EVELUT®: A Real-World, Observational Study Assessing Dyspnoea and Symptom Burden in COPD Patients Switched from LABA/ICS to LAMA/LABA or LAMA/LABA/ICS. Adv Ther 2023; 40:3263-3278. [PMID: 37256536 PMCID: PMC10230142 DOI: 10.1007/s12325-023-02524-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/14/2023] [Indexed: 06/01/2023]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD 2023) no longer recommends a long-acting β2-agonist (LABA) plus inhaled corticosteroid (ICS) combination for the treatment of chronic obstructive pulmonary disease (COPD). In patients treated with LABA/ICS, who continue to experience symptoms without frequent or severe exacerbations, GOLD now recommends switching to long-acting muscarinic antagonist (LAMA)/LABA instead of escalating to triple therapy (TT; LAMA/LABA/ICS), which previously was also a recommended option. EVELUT®, a real-life, observational study, compared these two treatment strategies in terms of symptom relief and health status improvement. METHODS Patients with symptomatic COPD at low exacerbation risk (GOLD B) were switched, at their physicians' discretion, from LABA/ICS to either fixed-dose LAMA/LABA (tiotropium/olodaterol, Respimat® [Tio/Olo]) or fixed or free TT. Primary endpoints were change in modified Medical Research Council (mMRC) and COPD Assessment Test™ (CAT™) scores after 12 weeks. RESULTS The safety set contained 463 patients (Tio/Olo, n = 329; TT, n = 134). In a propensity score-matched set (Tio/Olo, n = 121; TT, n = 121), improvement in mMRC score was similar in patients on Tio/Olo (-0.23; 95% confidence interval [CI] -0.11, -0.36) and TT (-0.25; 95% CI -0.13, -0.38). Improvement in total CAT score was slightly larger in patients on Tio/Olo (-3.45; 95% CI -2.45, -4.45) versus TT (-2.51; 95% CI -1.62, -3.40). In both groups, Physician's Global Evaluation scores increased, with 69-89% of patients satisfied with their treatment overall. Marginally more patients on Tio/Olo responded to treatment versus TT (Δ mMRC score ≥ 1; 25% vs. 22%; Δ CAT score ≥ 2, 68% vs. 56%). CONCLUSION In patients with symptomatic COPD at low exacerbation risk, treatment can be switched from LABA/ICS to LAMA/LABA without compromising clinical benefit, compared with escalating to LAMA/LABA/ICS. Switching from LABA/ICS to LAMA/LABA can provide symptom relief and improve health status without exposure to the risks associated with ICS. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT03954132.
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Mainz University Hospital, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Muriel Mattiucci-Guehlke
- HP Country Medical Affairs, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | | | | | - Christian Taube
- Department of Pulmonary Medicine, University Hospital Essen, Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Gießen and Marburg, German Center for Lung Research (DZL), Marburg, Germany
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Deslee G, Fabry-Vendrand C, Poccardi N, Thabut G, Eteve Pitsaer C, Coriat A, Renaudat C, Maguire A, Pinto T. Use and persistence of single and multiple inhaler triple therapy prescribed for patients with COPD in France: a retrospective study on THIN database (OPTI study). BMJ Open Respir Res 2023; 10:10/1/e001585. [PMID: 37263738 DOI: 10.1136/bmjresp-2022-001585] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION From 2018 single inhaler triple therapy (SITT) became available in France to treat moderate-to-severe chronic obstructive pulmonary disease (COPD). Given its simplified inhaler use compared with multiple inhaler triple therapy (MITT), this therapeutic option has the potential to offer benefit in terms of improved persistence and adherence. Given the lack of real-world evidence of the effectiveness of triple therapy, this study was designed to evaluate the use of MITT and SITT in France and compare persistence. METHODS A retrospective cohort study was performed. Patients with COPD who initiated triple therapy between 1 July 2017 and 31 December 2019 were included from The Health Improvement Network, a large electronic medical database in France, which includes pharmacy data. A 60-day treatment gap defined discontinuation and thereby persistence. RESULTS A total of 3134 patients initiated triple therapy for COPD in the study period, among them 485 with SITT. In 2019, the rate of use of SITT was 28.2%. The mean age (67.3 years) and sex (44.2% female) of patients initiating triple therapy was similar between MITT and SITT, and most patients had escalated from dual therapy (84.1%). However, SITT was more frequently initiated by a pulmonologist (59.8%) and a higher prevalence of comorbid asthma was observed for SITT (47.0% vs 37.9%). Persistence was assessed among patients who did not discontinue after a single dispensation of triple therapy (n=1674). Median persistence was 181 days for SITT and 135 days for MITT, and the covariate-adjusted HR for persistence was 1.47 (p<0.001) and the estimated persistence at 1 year was 33% for SITT compared with 18% for MITT. DISCUSSION This study suggests that persistence was higher for the patients treated with SITT compared with MITT in France. Moreover, most patients initiated with triple therapy were previously treated with dual therapy and had exacerbations in the previous year.
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Affiliation(s)
- Gaétan Deslee
- Service de Pneumologie, INSERM UMRS-1250, CHU de Reims, Université Reims Champagne-Ardenne, CHU de Reims, Reims, France
| | | | | | | | | | | | | | | | - Thomas Pinto
- Médecin généraliste, Chef de clinique universitaire, Université de Paris, Paris, France
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Kocks J, Ferreira AJ, Bakke P, van Schayck OCP, Ekroos H, Tzanakis N, Soulard S, Haaksma-Herczegh M, Mestres-Simon M, Águila-Fuentes M, Cataldo D. Investigating the rationale for COPD maintenance therapy prescription across Europe, findings from a multi-country study. NPJ Prim Care Respir Med 2023; 33:18. [PMID: 37137900 PMCID: PMC10154184 DOI: 10.1038/s41533-023-00334-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 02/20/2023] [Indexed: 05/05/2023] Open
Abstract
This study aims to understand healthcare professionals' thoughts and motivations about optimal management and treatment of patients with chronic obstructive pulmonary disease (COPD). We conducted a DELPHI survey through an online questionnaire distributed to 220 panellists from six European countries and a discrete choice experiment to describe the relationship between selected clinical criteria and the initial COPD treatment of choice. One hundred twenty-seven panellists (general practitioners [GPs] and pulmonologists) completed the survey. Despite the familiarity and use (89.8%) of the GOLD classification for initial treatment selection, a frequent use of LAMA/LABA/ICS was noted. In fact, panellists agreed that inhaled corticosteroids (ICS) are over-prescribed in the primary care setting. Our study showed that GPs felt less confident than pulmonologists with ICS withdrawal. This mismatch observed between best practice and behaviour indicates the need to increase awareness and efforts to improve the adherence to guidelines in clinical practice.
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Affiliation(s)
- Janwillem Kocks
- General Practitioners Research Institute, Groningen, The Netherlands.
- Observational and Pragmatic Research Institute, Singapore, Singapore.
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - António Jorge Ferreira
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Pulmonology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Per Bakke
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Onno C P van Schayck
- Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Heikki Ekroos
- Department of Pulmonary Medicine, Porvoo Hospital, Porvoo, Finland
| | - Nikolaos Tzanakis
- Department of Thoracic Medicine, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece
| | | | | | | | | | - Didier Cataldo
- Department of Respiratory Medicine, Centre Hospitalier Universitaire de Liège (CHU) and University of Liège, Liège, Belgium
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Lee JH, Kim S, Oh YM. A Prediction Scoring Model for the Effect of Withdrawal or Addition of Inhaled Corticosteroids in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2023; 18:113-127. [PMID: 36815055 PMCID: PMC9939789 DOI: 10.2147/copd.s389502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/02/2023] [Indexed: 02/17/2023] Open
Abstract
Purpose The aims of this study were to develop a scoring model that predicts the effects of withdrawing inhaled corticosteroids (ICSs) from triple therapy and to examine its adaptability when applied to assess the effect of adding ICSs to dual bronchodilators patients with chronic obstructive pulmonary disease (COPD). Patients and Methods A scoring model was developed using the IMPACT study dataset, consisting of 2389 COPD patients treated with triple therapy before enrollment (ICS withdrawal dataset). The developed model consisted of COPD duration, Acute exacerbation history, Sex, Pulmonary function tests, blood Eosinophil count, and Race (CASPER) and was used to predict composite events of moderate-to-severe exacerbation, all-cause mortality, and pneumonia. Treatment heterogeneity was assessed using Cox interaction analyses. The CASPER model was applied to 540 COPD patients treated with dual bronchodilator before enrollment (ICS addition dataset). Validity was assessed using Harrell's C-index, time-dependent receiver operating characteristic curves, and calibration plots. Results The cumulative incidence of the composite event was 60.1% over 12 months in the ICS withdrawal dataset. Cox interaction analyses revealed that ICS was different according to race and blood eosinophil counts. The hazard ratios (HRs) for dual bronchodilator compared with triple therapy were 1.318 (95% confidence interval (CI)=1.170-1.485; P-value <0.001) in whites and 0.922 (95% CI = 0.712-1.195; P-value=0.541) in other races. The treatment effect was different in the eosinophil count ≥0.3 group (HR = 1.586; 95% CI = 1.274-1.975) and in the eosinophil count = 0.1-0.3 group (HR = 1.211; 95% CI = 1.041-1.408), but it was same in the eosinophil count <0.1 (HR = 1.009; P-value=0.940). The CASPER model performed well with good discrimination and calibration, which were superior to the prediction based on exacerbation history and blood eosinophil count. Conclusion The presented CASPER model might be able to predict and compare the risk of composite events when dual bronchodilator or triple therapy is administered to COPD patients.
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Affiliation(s)
- Jang Ho Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Mok Oh
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea,Correspondence: Yeon-Mok Oh, Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea, Tel +82-2-3010-3136, Fax +82-2-3010-6968, Email
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Kaczyńska K, Jampolska M, Wojciechowski P, Sulejczak D, Andrzejewski K, Zając D. Potential of Lactoferrin in the Treatment of Lung Diseases. Pharmaceuticals (Basel) 2023; 16:192. [PMID: 37259341 PMCID: PMC9960651 DOI: 10.3390/ph16020192] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 11/07/2023] Open
Abstract
Lactoferrin (LF) is a multifunctional iron-binding glycoprotein that exhibits a variety of properties, such as immunomodulatory, anti-inflammatory, antimicrobial, and anticancer, that can be used to treat numerous diseases. Lung diseases continue to be the leading cause of death and disability worldwide. Many of the therapies currently used to treat these diseases have limited efficacy or are associated with side effects. Therefore, there is a constant pursuit for new drugs and therapies, and LF is frequently considered a therapeutic agent and/or adjunct to drug-based therapies for the treatment of lung diseases. This article focuses on a review of the existing and most up-to-date literature on the contribution of the beneficial effects of LF on the treatment of lung diseases, including asthma, viral infections, cystic fibrosis, or lung cancer, among others. Although in vitro and in vivo studies indicate significant potency of LF in the treatment of the listed diseases, only in the case of respiratory tract infections do human studies seem to confirm them by demonstrating the effectiveness of LF in reducing episodes of illness and shortening the recovery period. For lung cancer, COVID-19 and sepsis, the reports are conflicting, and for other diseases, there is a paucity of human studies conclusively confirming the beneficial effects of LF.
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Affiliation(s)
- Katarzyna Kaczyńska
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Monika Jampolska
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Piotr Wojciechowski
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Dorota Sulejczak
- Department of Experimental Pharmacology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Kryspin Andrzejewski
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Dominika Zając
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
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Miravitlles M, Matsunaga K, Dreher M. Stepwise management of COPD: What is next after bronchodilation? Ther Adv Respir Dis 2023; 17:17534666231208630. [PMID: 37936381 PMCID: PMC10631322 DOI: 10.1177/17534666231208630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, University Hospital Vall d′Hebron/Vall d’Hebron Research Institute (VHIR, Vall d’Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias [CIBERES]), P. Vall d’Hebron 119–129, Barcelona 08035, Spain
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
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11
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Miravitlles M, Kawayama T, Dreher M. LABA/LAMA as First-Line Therapy for COPD: A Summary of the Evidence and Guideline Recommendations. J Clin Med 2022; 11:jcm11226623. [PMID: 36431099 PMCID: PMC9692772 DOI: 10.3390/jcm11226623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/27/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022] Open
Abstract
Inhaled bronchodilators (alone or in combination) are the cornerstone of treatment for symptomatic patients with COPD, either as initial/first-line treatment or for second-line/treatment escalation in patients who experience persistent symptoms or exacerbations on monotherapy. The Global Initiative for Chronic Obstructive Lung Disease 2022 report recommends initial pharmacological treatment with a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA) as monotherapy for most patients, or dual bronchodilator therapy (LABA/LAMA) in patients with more severe symptoms, regardless of exacerbation history. The recommendations for LABA/LAMA are broader in the American Thoracic Society treatment guidelines, which strongly recommend LABA/LAMA combination therapy over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance. However, despite consistent guideline recommendations, real-world prescribing data indicate that LAMA and/or LABA without an inhaled corticosteroid are not the most widely prescribed therapies in COPD. This article reviews global and regional/national guideline recommendations for the use of LABA/LAMA in COPD, examines the evidence for the effectiveness and safety of LABA/LAMA versus other therapies and offers a practical guide for clinicians to help ensure appropriate use of LABA/LAMA therapy.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d′Hebron, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Correspondence: ; Tel.: +34-(93)-274-6157
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, 52074 Aachen, Germany
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12
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Inhaled Corticosteroid Withdrawal and Change in Lung Function in Primary Care Patients with Chronic Obstructive Pulmonary Disease in England. Ann Am Thorac Soc 2022; 19:1834-1841. [PMID: 35767034 DOI: 10.1513/annalsats.202111-1238oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: In chronic obstructive pulmonary disease (COPD), inhaled corticosteroids (ICS) are associated with pneumonia, highlighting the importance of investigating subgroups of patients who may benefit from prolonged ICS use. Despite this, the WISDOM (Withdrawal of Inhaled Steroids during Optimized Bronchodilator Management) trial found a greater decline in forced expiratory volume in 1 second (FEV1) in patients with COPD who withdrew from ICS compared with patients who remained on triple therapy. Objectives: We investigated the association between ICS withdrawal and the rate of FEV1 decline in patients with COPD using routinely collected electronic healthcare records. Methods: Using CPRD (Clinical Practice Research Datalink) Aurum and Hospital episode statistics, we included patients with COPD who had been on triple therapy for at least 4 months. Patients were categorized into those who withdrew from ICS and those who remained on triple therapy during follow-up. Three cohorts were created: 1) patients meeting the WISDOM trial eligibility criteria; 2) patients with COPD not restricted by the WISDOM trial eligibility criteria; and 3) patients who would have been excluded from the WISDOM trial on the basis of their comorbidities. Mixed linear regression was used to model the association between ICS withdrawal and the rate of FEV1 decline (ml/year) adjusted for baseline characteristics. Results: A total of 6,008 patients with COPD met the WISDOM eligibility criteria, of which 9.0% withdrew from ICS. Mean rates of FEV1 declined -7.8 ml/year (95% confidence interval [CI], -19.7 to 4.1) for withdrawers and -15.2 ml/year (95% CI, -18.7 to -11.8) for those who remained on triple therapy (difference, P = 0.264). A total of 60,645 patients with COPD were not restricted by the WISDOM eligibility criteria. The mean rate of FEV1 decline was -32.6 ml/year (95% CI, -33.6 to -31.5) for withdrawers and -36.4 ml/year (95% CI, -39.4 to -33.4) for those who remained on triple therapy. A total of 32,882 patients with COPD were included in the last population representing those who would have been excluded from the WISDOM trial because of their comorbidities. The mean rate of FEV1 decline was -29.4 ml/year (95% CI, -30 to -28.1) in withdrawers and -31.3 ml/year (95% CI, -35 to -27.5) in those who remained on triple therapy. Conclusions: The rate of FEV1 decline was similar between patients on triple therapy and patients who withdrew from ICS regardless of the specific COPD population studied. In routine clinical practice, few patients with COPD meet WISDOM eligibility criteria, and few patients are withdrawn from ICS.
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13
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Neches García V, Vallejo-Aparicio LA, Ismaila AS, Sicras-Mainar A, Sicras-Navarro A, González C, Cuervo R, Shukla S, García-Peñuela M. Clinical and Economic Impact of Long-Term Inhaled Corticosteroid Withdrawal in Patients with Chronic Obstructive Pulmonary Disease Treated with Triple Therapy in Spain. Int J Chron Obstruct Pulmon Dis 2022; 17:2161-2174. [PMID: 36101793 PMCID: PMC9464437 DOI: 10.2147/copd.s367708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the clinical and economic impact of inhaled corticosteroid (ICS) withdrawal in Spanish patients with COPD receiving triple therapy (TT) with ICS, long-acting β2-agonist (LABA), and long-acting muscarinic antagonist (LAMA). Patients and Methods This was an observational, retrospective study of BIG-PAC database medical records. Patients aged ≥40 years receiving TT from 2016 to 2018 were followed for 1 year. Two cohorts were identified: patients continuing TT (ICS+LABA+LAMA), and patients receiving TT with ICS withdrawn (LABA+LAMA). Variables included medication, exacerbations (moderate and severe), pneumonia, mortality, health resource use (HRU), and cost per patient/year. Cohorts were compared using propensity score matching (PSM). Multivariate statistical analysis using analysis of covariance and Cox proportional risks was conducted. Results Of 6541 patients included, 5740 (87.8%) continued TT and 801 (12.2%) had ICS withdrawn. Patients with ICS withdrawal were younger, had lower disease burden, higher ICS doses, and more exacerbations compared with those continuing ICS. PSM matched 795 patients in each cohort. Mean age was 68.5 years (SD: 11.2), 69.9% were male, and mean Charlson index was 2.0. Patients with ICS withdrawal had more total exacerbations in the 12 months following withdrawal compared with patients continuing TT (36.6% vs 31.4%; p=0.030). No significant differences were found for pneumonia (3.3% vs 3.6%; p=0.583) and mortality (9.9% vs 7.5%; p=0.092). Median time to first exacerbation was shorter in patients with ICS withdrawal compared with those continuing ICS (HR: 0.69, 95% CI: 0.57–0.83; p<0.001). Mean health cost per patient/year among patients with ICS withdrawal was higher than those continuing TT (€2993 vs €2130; p<0.001). Conclusion ICS withdrawal in patients with COPD receiving TT was associated with increased exacerbations, HRU, and costs compared with continuing TT, with health and economic impacts on patients and the Spanish National Healthcare System, respectively. Pneumonia and mortality rates were similar between groups.
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Affiliation(s)
| | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | | | - Cruz González
- Pneumology Unit, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Soham Shukla
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA
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14
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The Role of Dual Bronchodilation and the Conscientious Use of Inhaled Corticosteroid in COPD. SINUSITIS 2022. [DOI: 10.3390/sinusitis6020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a global public health burden that stands out as a leading cause of mortality around the world, especially in less developed countries. COPD treatment should be centered on the individual necessities of each patient, integrating pharmacological therapy, immunization, nutritional support, pulmonary rehabilitation and control of comorbidities. Combining a long-acting antimuscarinic (LAMA) with a long-acting beta2-agonist (LABA) bronchodilator has proven to be more effective than monotherapy with LABA or LAMA, in terms of the functional improvement of forced expiratory volume (FEV1), symptoms and life quality and may be helpful in patients with progressive dyspnea. The eosinophil blood count is a simple biomarker that could guide personalized treatment strategies by identifying patients with greater clinical benefits of inhaled corticosteroid (ICS) treatment. However, one critical concern is the increased risk of pneumonia in individuals treated with ICS.
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15
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Miravitlles M, González-Torralba F, Represas-Represas C, Pomares X, Márquez-Martín E, González C, Amado C, Forné C, Alonso S, Alcázar B, Barrecheguren M, Jurado Mirete JM, Naval E. Pulmonologists' Opinion on the Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Patients in Spain: A Cross-Sectional Survey. Int J Chron Obstruct Pulmon Dis 2022; 17:1577-1587. [PMID: 35855745 PMCID: PMC9288191 DOI: 10.2147/copd.s369118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD. Methods A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal. Results A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction. Conclusion In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain
| | | | | | - Xavier Pomares
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Pneumology Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Eduardo Márquez-Martín
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Medical-Surgical Unit for Respiratory Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Cruz González
- Pneumology Department, Hospital Clínico de Valencia, Valencia, Spain
| | - Carlos Amado
- Pneumology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carles Forné
- Heorfy Consulting, Lleida, Spain.,Basic Medical Sciences Department, University of Lleida, Lleida, Spain
| | - Soledad Alonso
- Pneumology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Bernardino Alcázar
- Pneumology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Elsa Naval
- Pneumology Department, Hospital Universitario de La Ribera, Alzira, Spain
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16
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Yu I, Park S, Hong SH, Chang MS, Lee SJ, Yong SJ, Lee WY, Kim SH, Lee JH. Risk of Tuberculosis Caused by Fluticasone Propionate versus Budesonide in Chronic Obstructive Pulmonary Disease: A Nationwide Population-Based Study. J Pers Med 2022; 12:jpm12071189. [PMID: 35887686 PMCID: PMC9321025 DOI: 10.3390/jpm12071189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/09/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022] Open
Abstract
Background: In chronic obstructive pulmonary disease (COPD), inhaled corticosteroids (ICSs) are recommended for use by patients with frequent exacerbations and blood eosinophilia. However, ICSs are often inappropriately prescribed and overused. COPD studies have reported an increased risk of tuberculosis among ICS users. This study aimed to compare the risk of tuberculosis according to the different ICS components. Methods: This study was conducted using a nationwide, population-based cohort. Patients newly diagnosed with COPD between 2005 and 2018, and treated with either fluticasone propionate or budesonide, were selected. The patients were followed up until the development of tuberculosis. Results: After propensity score matching, 16,514 fluticasone propionate and 16,514 budesonide users were identified. The incidence rate of tuberculosis per 100,000 person-years was 274.73 for fluticasone propionate and 214.18 for budesonide. The hazard ratio of tuberculosis in fluticasone propionate compared with budesonide was 1.28 (95% confidence interval 1.05–1.60). The risk of tuberculosis for fluticasone propionate increased with higher ICS cumulative doses: 1.01 (0.69–1.48), 1.16 (0.74–1.81), 1.25 (0.79–1.97), and 1.82 (1.27–2.62) from the lowest to highest quartiles, respectively. Conclusion: Fluticasone propionate is associated with a higher risk of tuberculosis than budesonide. ICS components can differently affect the risk of tuberculosis in patients with COPD.
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Affiliation(s)
- Iseul Yu
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Sunmin Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Se Hwa Hong
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Min-Seok Chang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Seok Jeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Suk Joong Yong
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Sang-Ha Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
- Correspondence:
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17
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Patel S, Dickinson S, Morris K, Ashdown HF, Chalmers JD. A descriptive cohort study of withdrawal from inhaled corticosteroids in COPD patients. NPJ Prim Care Respir Med 2022; 32:25. [PMID: 35859081 PMCID: PMC9300648 DOI: 10.1038/s41533-022-00288-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 06/10/2022] [Indexed: 11/15/2022] Open
Abstract
Inhaled corticosteroid (ICS) therapy is widely prescribed without a history of exacerbations and consensus guidelines suggest withdrawal of ICS in these patients would reduce the risk of side effects and promote cost-effective prescribing. The study describes the prescribing behaviour in the United Kingdom (UK) in relation to ICS withdrawal and identifies clinical outcomes following withdrawal using primary and secondary care electronic health records between January 2012 and December 2017. Patients with a history ≥12 months’ exposure who withdrew ICS for ≥6 months were identified into two cohorts; those prescribed a long-acting bronchodilator maintenance therapy and those that were not prescribed any maintenance therapy. The duration of withdrawal, predictors of restarting ICS, and clinical outcomes were compared between both patient cohorts. Among 76,808 patients that had ≥1 prescription of ICS in the study period, 11,093 patients (14%) withdrew ICS therapy at least once during the study period. The median time without ICS was 9 months (IQR 7–14), with the majority (71%) receiving subsequent ICS prescriptions after withdrawal. Patients receiving maintenance therapy with a COPD review at withdrawal were 28% less likely to restart ICS (HR: 0.72, 95% CI 0.61, 0.85). Overall, 69% and 89% of patients that withdrew ICS had no recorded exacerbation event or COPD hospitalisation, respectively, during the withdrawal. This study provides evidence that most patients withdrawing from ICS do not experience COPD exacerbations and withdrawal success can be achieved by carefully planning routine COPD reviews whilst optimising the use of available maintenance therapies.
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Affiliation(s)
- Smit Patel
- Boehringer Ingelheim Ltd, Bracknell, UK.
| | | | | | - Helen F Ashdown
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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18
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Roche N, Crichton ML, Goeminne PC, Cao B, Humbert M, Shteinberg M, Antoniou KM, Suppli Ulrik C, Parks H, Wang C, Vandendriessche T, Qu J, Stolz D, Brightling C, Welte T, Aliberti S, Simonds AK, Tonia T, Chalmers JD. Update March 2022: management of hospitalised adults with coronavirus disease-19 (COVID-19): a European Respiratory Society living guideline. Eur Respir J 2022; 60:13993003.00803-2022. [PMID: 35710264 PMCID: PMC9363848 DOI: 10.1183/13993003.00803-2022] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 05/31/2022] [Indexed: 12/15/2022]
Abstract
Since the identification of SARS-CoV-2 at the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has affected more than 410 million people worldwide and killed almost 6 million [1, 2]. The predecessors of COVID-19, i.e. the SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) outbreaks, had been relatively self-limiting, preventing clinicians and researchers from establishing evidence-based specific therapeutic strategies [3]. Conversely, COVID-19 rapidly proved to be extremely fast spreading, which led stakeholders to encourage, guide, build or fund multidirectional therapeutic research strategies based on both repurposing and development of new agents [4–8]. In parallel, considerable efforts were directed at describing the disease and understanding the underlying mechanisms [9–13]. As a result, there has been a huge generation of evidence, as highlighted by the impressive number of COVID-19 publications (more than 200 000 since the end of 2019). As a consequence, it proved rapidly impossible for any clinician, researcher or decision-maker to gather and analyse all the corresponding literature to derive appropriate guidance [14]. The first step of such a process is to select the relevant high-quality research that can be used to answer the question(s) of interest [15]. Even if limiting the search to clinical trials, systematic reviews and meta-analyses, almost 4000 papers appear in the PubMed database, as of mid-February 2022. In June and July 2020, the European Respiratory Society (ERS) and the American Thoracic Society (ATS) released early guidance on several aspects of COVID-19 management (i.e. rehabilitation, palliative care and acute management); at that time, direct specific evidence was sparse or absent [16–18]. Simultaneously, the ERS launched a living guideline on the management of COVID-19. The format was that of a “short” guideline, as per ERS standards [19, 20], in that the purpose was to release the first iteration within 12 months. However, the number of PICO (Population, Intervention, Comparator, Outcomes) questions to be addressed (n=12) already exceeded markedly what the ERS considers as being feasible during such a short timeframe (i.e. n=1–2), which was a direct consequence of the high number of unanswered issues in the field of acute COVID-19 management, all corresponding to outstanding clinical needs. The first version of these guidelines was published in March 2021 and addressed the following potential therapeutic options: corticosteroids, interleukin (IL)-6 receptor antagonists, hydroxychloroquine, azithromycin and both combined, colchicine, lopinavir-ritonavir, remdesivir, interferon-β, anticoagulation and non-invasive ventilatory support [6, 21]. An update of the mortality meta-analyses for corticosteroids, hydroxychloroquine, azithromycin, remdesivir, anti-IL-6 monoclonal antibodies, colchicine, lopinavir/ritonavir and interferon-β was published in December 2021 [22]. The ERS COVID-19 guidelines make recommendations for corticosteroids, anti-IL-6 monoclonal antibodies, baricitinib, anticoagulation and non-invasive respiratory support for hospitalised patients with COVID-19 https://bit.ly/3QgHH7U
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Affiliation(s)
- Nicolas Roche
- Respiratory Medicine, Cochin Hospital, APHP Centre-University of Paris, Cochin Institute (INSERM UMR1016), Paris, France
| | | | | | - Bin Cao
- Department of Respiratory and Critical Care Medicine, Clinical Microbiology and Infectious Disease Lab, China-Japan Friendship Hospital, National Center for Respiratory Medicine, Institute of Respiratory Medicine, Chinese Academy of Medical Science, National Clinical Research Center of Respiratory Diseases, Beijing, China
| | - Marc Humbert
- Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP); Université Paris-Saclay; Inserm UMR_S 999, Le Kremlin Bicêtre, France
| | - Michal Shteinberg
- Pulmonology institute and CF Center, Carmel Medical Center and the Technion- Israel Institute of Technology, Haifa, Israel
| | - Katerina M Antoniou
- Laboratory of Molecular and Cellular Pneumonology, Department of Respiratory Medicine, School of Medicine, University of Crete, Heraklion, Greece
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre Hospital, Hvidovre, Denmark
| | | | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center of Respiratory Diseases, Beijing, China
| | | | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai, China; Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | | | - Tobias Welte
- Medizinische Hochschule Hannover, Direktor der Abteilung Pneumologie, Hannover, Germany
| | - Stefano Aliberti
- University of Milan, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anita K Simonds
- Respiratory and Sleep Medicine, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University Bern, Bern, Switzerland
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19
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Christenson SA, Smith BM, Bafadhel M, Putcha N. Chronic obstructive pulmonary disease. Lancet 2022; 399:2227-2242. [PMID: 35533707 DOI: 10.1016/s0140-6736(22)00470-6] [Citation(s) in RCA: 190] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 02/16/2022] [Accepted: 02/25/2022] [Indexed: 12/14/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity, mortality, and health-care use worldwide. COPD is caused by exposure to inhaled noxious particles, notably tobacco smoke and pollutants. However, the broad range of factors that increase the risk of development and progression of COPD throughout the life course are increasingly being recognised. Innovations in omics and imaging techniques have provided greater insight into disease pathobiology, which might result in advances in COPD prevention, diagnosis, and treatment. Although few novel treatments have been approved for COPD in the past 5 years, advances have been made in targeting existing therapies to specific subpopulations using new biomarker-based strategies. Additionally, COVID-19 has undeniably affected individuals with COPD, who are not only at higher risk for severe disease manifestations than healthy individuals but also negatively affected by interruptions in health-care delivery and social isolation. This Seminar reviews COPD with an emphasis on recent advances in epidemiology, pathophysiology, imaging, diagnosis, and treatment.
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Affiliation(s)
- Stephanie A Christenson
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Benjamin M Smith
- Department of Medicine, Columbia University Medical Center, New York, NY, USA; Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Mona Bafadhel
- School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Department of Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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20
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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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21
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Santos NCD, Miravitlles M, Camelier AA, Almeida VDCD, Maciel RRBT, Camelier FWR. PREVALENCE AND IMPACT OF COMORBIDITIES IN INDIVIDUALS WITH COPD: A SYSTEMATIC REVIEW. Tuberc Respir Dis (Seoul) 2022; 85:205-220. [PMID: 35618259 PMCID: PMC9263346 DOI: 10.4046/trd.2021.0179] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022] Open
Abstract
This study aimed to describe the prevalence of comorbidities associated with chronic obstructive pulmonary disease (COPD) and their relation with relevant outcomes. A systematic review based on the PRISMA methodology was performed from January 2020 until July 2021. The MEDLINE, Lilacs, and Scielo databases were searched to identify studies related to COPD and its comorbidities. Observational studies on the prevalence of comorbidities in COPD patients and costs with health estimates, reduced quality of life, and mortality were included. Studies that were restricted to one or more COPD pain assessments and only specific comorbidities such as osteoporosis, bronchitis, and asthma were excluded. The initial search identified 1,409 studies and after applying the inclusion and exclusion criteria, 20 studies were finally selected for analysis (comprising data from 447,459 COPD subjects). The most frequent COPD comorbidities were: hypertension (range, 17%–64.7%), coronary artery disease (19.9%–47.8%), diabetes (10.2%–45%), osteoarthritis (18%–43.8%), psychiatric conditions (12.1%–33%), and asthma (14.7%–32.5%). Several comorbidities had an impact on the frequency and severity of COPD exacerbations, quality of life, and mortality risk, in particular malignancies, coronary artery disease, chronic heart failure, and cardiac arrhythmias. Comorbidities, especially cardiovascular diseases and diabetes, are frequent in COPD patients, and some of them are associated with higher mortality.
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22
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Cazzola M, Ora J, Calzetta L, Rogliani P, Matera MG. Advances in inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease: what is their value today? Expert Opin Pharmacother 2022; 23:917-927. [PMID: 35575510 DOI: 10.1080/14656566.2022.2076592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION As of today, there is still a need to determine which COPD patients may benefit from ICS therapy, whether ICSs are useful in COPD patients without chronic bronchitis, and whether long-acting bronchodilators can reduce the risk of exacerbations in frequent exacerbators even if ICSs are not used, and whether combination therapy including ICSs is helpful in infrequent exacerbators to optimise the use of ICSs in COPD. Nevertheless, in recent years, a fair amount of evidence has been produced that, at least in part, can help define the role of ICSs in COPD better. AREAS COVERED Herein, the authors provide an overview of current use of ICS in COPD and discuss their value to the current treatment armamentarium. The article includes discussion of which patients will benefit best from the use of ICSs, their potential uses and adverse effects. EXPERT OPINION There is growing agreement on why, in whom, and when ICS therapy can be used in COPD, although the consensus is still lacking because of the heterogeneity of COPD. The use of blood eosinophil counts (BECs) is only helpful in T2 inflammation, while there is a lack of biomarkers indicating the presence of T1 and T17 immunity, which is poorly responsive to ICS. Identifying ICS-sensitive endotypes using specific biomarkers that have yet to be identified and validated is likely to demonstrate that ICSs can influence the natural course of COPD in at least a subset of patients.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Josuel Ora
- Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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23
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Ding Y, Sun L, Wang Y, Zhang J, Chen Y. Efficacy of ICS versus Non-ICS Combination Therapy in COPD: A Meta-Analysis of Randomised Controlled Trials. Int J Chron Obstruct Pulmon Dis 2022; 17:1051-1067. [PMID: 35547781 PMCID: PMC9084385 DOI: 10.2147/copd.s347588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/24/2022] [Indexed: 12/15/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Yanling Ding
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Lina Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Ying Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
- Correspondence: Jing Zhang; Yahong Chen, Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China, Tel +86 13-8104-57631, Email ;
| | - Yahong Chen
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
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24
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Dalin DA, Løkke A, Kristiansen P, Jensen C, Birkefoss K, Christensen HR, Godtfredsen NS, Hilberg O, Rohde JF, Ussing A, Vermehren C, Handel MN. A systematic review of blood eosinophils and continued treatment with inhaled corticosteroids in patients with COPD. Respir Med 2022; 198:106880. [DOI: 10.1016/j.rmed.2022.106880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/04/2022] [Accepted: 05/10/2022] [Indexed: 12/15/2022]
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25
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Zysman M, Baptista BR, Soumagne T, da Silva VM, Martin C, de Menonville CT, Boyer L, Degano B, Burgel PR, Perez T, Bourdin A, Raherison C, Pégliasco H, Piperno D, Zanetti C, Morel H, Delclaux B, Delafosse C, Lorenzo A, Housset B, Morélot-Panzini C, Chabot F, Devillier P, Deslée G, Roche N. Position paper of the French Society of Respiratory Diseases regarding pharmacological treatment optimization for stable COPD in 2021. Respir Med Res 2022; 81:100889. [PMID: 35219225 DOI: 10.1016/j.resmer.2022.100889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Maeva Zysman
- Univ-Bordeaux, Centre de Recherche cardio-thoracique de Bordeaux, U1045, CIC 1401, F-33604 Pessac, France; Service des Maladies Respiratoires, CHU Bordeaux, Bordeaux, France.
| | - Bruno Ribeiro Baptista
- Université Paris-Est, UMR S955, UPEC, F-94000, Créteil, France; Département de Pneumologie-CHRU Nancy-Université de Lorraine, Vandœuvre-lès-Nancy, Inserm, U1116; Université de Lorraine, Nancy, France
| | - Thibaud Soumagne
- Service de Pneumologie, Oncologie Thoracique et Allergologie Respiratoire, CHU de Besançon, France
| | | | - Clémence Martin
- Department of Respiratory Medicine, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | | | - Laurent Boyer
- Université Paris-Est, UMR S955, UPEC, F-94000, Créteil, France; Département de physiologie-explorations fonctionnelles, AP-HP Hôpital Henri-Mondor, Créteil, France
| | - Bruno Degano
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, France; Université Grenoble Alpes, Grenoble, France
| | - Pierre-Régis Burgel
- Department of Respiratory Medicine, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | - Thierry Perez
- Service de Pneumologie, CHU Lille, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Lille, France
| | - Arnaud Bourdin
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France; Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Chantal Raherison
- Service des Maladies Respiratoires, CHU Bordeaux, Bordeaux, France; Bordeaux Population Health Research Center, Univ. Bordeaux, INSERM, Team EPICENE, UMR 1219, Bordeaux, France
| | | | | | | | - Hughes Morel
- Service de pneumologie d'allergologie et d'oncologie thoracique, CHR d'Orléans, 45067 Orléans, France
| | - Bertrand Delclaux
- Service de pneumologie, centre hospitalier de Troyes, 10003 Troyes, France
| | | | - Alain Lorenzo
- Médecine Sorbonne Université, Département de médecine générale, Paris, France
| | - Bruno Housset
- Pulmonary Department, CHI de Créteil, University Paris Est Créteil, Créteil, France
| | | | - François Chabot
- Département de Pneumologie-CHRU Nancy-Université de Lorraine, Vandœuvre-lès-Nancy, Inserm, U1116; Université de Lorraine, Nancy, France
| | - Philippe Devillier
- Department of Airway Diseases, UPRES EA 220, Foch Hospital, Paris-Saclay University, Suresnes, France
| | - Gaëtan Deslée
- Service de Pneumologie, INSERM U1250, CHU Reims, Université Reims Champagne Ardenne, Reims, France
| | - Nicolas Roche
- Department of Respiratory Medicine, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
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Suissa S, Dell'Aniello S, Ernst P. Discontinuation of Inhaled Corticosteroids from Triple Therapy in COPD: Effects on Major Outcomes in Real World Clinical Practice. COPD 2022; 19:133-141. [PMID: 35392746 DOI: 10.1080/15412555.2022.2045265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Recent reports provide evidence-based guidelines for the withdrawal of inhaled corticosteroids (ICS) in COPD, but data on patients treated with ICS-based triple therapy are sparse and contradictory. We assessed the effect of ICS discontinuation on the incidence of severe exacerbation and pneumonia in a real-world population of patients with COPD who initiated triple therapy. We identified a cohort of patients with COPD treated with LAMA-LABA-ICS triple therapy during 2002-2018, age 50 or older, from the UK's CPRD database. Subjects who discontinued ICS were matched 1:1 on time-conditional propensity scores to those continuing ICS and followed for one year. Hazard ratios (HR) of severe exacerbation and pneumonia were estimated using Cox regression. The cohort included 42,667 patients who discontinued ICS matched to 42,667 who continued ICS treatment. The hazard ratio of a severe exacerbation with ICS discontinuation relative to ICS continuation was 0.86 (95% CI: 0.78-0.95), while for severe pneumonia it was 0.96 (95% CI: 0.88-1.05). The incidence of severe exacerbation after ICS discontinuation was numerically higher than after continuation among patients with two or more exacerbations in the prior year (HR 1.09; 95% CI: 0.94-1.26) and among those with FEV1 <30% predicted (HR 1.29; 95% CI: 1.04-1.59). This large real-world study in the clinical setting of COPD treatment suggests that certain patients on triple therapy can be safely withdrawn from ICS and remain on bronchodilator therapy. As residual confounding cannot be ruled out, ICS discontinuation is not warranted for patients with multiple exacerbations and with very severe airway obstruction.
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada.,Departments of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Québec, Canada
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada.,Departments of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Québec, Canada
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Efficacy and Safety of Re Du Ning Injection for Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:7479639. [PMID: 35356238 PMCID: PMC8959946 DOI: 10.1155/2022/7479639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/23/2022] [Indexed: 11/17/2022]
Abstract
Background Re Du Ning, a traditional Chinese medicine injection, has been widely used for the treatment of chronic obstructive pulmonary disease, although without established systematic review evidence. This systematic review aimed to assess the efficacy and safety of Re Du Ning in the treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Methods We searched seven databases (PubMed, Embase, the Cochrane Library, SinoMed, CNKI, WanFang, and the Chinese Clinical Trial Registry) up to November 1, 2021, to identify randomized controlled trials of Re Du Ning for AECOPD. Two researchers independently carried out literature screening and data extraction. Effects were measured by risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs). The meta-analysis was completed by RevMan 5.4 software. Results Twenty-six studies met the eligibility criteria, with a total of 2284 patients. The findings of the meta-analysis indicated that the response rate of the experimental group was higher than that of the control group: RR = 1.14% and 95% CI: (1.09, 1.19). Significantly greater improvements in pulmonary function: FEV1: MD = 0.28 L, 95% CI: (0.20, 0.36); FEV1/FVC: MD = 8.63%, 95% CI: (4.68, 12.59); T-lymphocyte counts: CD4: MD = 6%, 95% CI: (2.44, 9.56); CD3: MD = 10.42%, 95% CI: (8.6, 12.24); CD4/CD8: MD = 0.38%, 95% CI: (0.32, 0.43); acid/base imbalance: PH: MD = 0.05, 95% CI: (0.01, 0.10); PaO2: MD = 9.02 mmHg, 95% CI: (11.11, 0.10), p=0.005; C-reactive protein: MD = -6.65 mg/L, 95% CI: (-10.97, -2.34); and PCT: MD = -0.28 μg/L, 95% (CI: -0.41, -0.15) were observed in patients receiving Re Du Ning compared with those receiving the control treatment. Re Du Ning did not significantly change the carbon dioxide partial pressure. All reported adverse reactions were mild. Conclusion Re Du Ning injection, as a complementary therapy to routine treatment, has better efficacy than Western medicine alone in relieving clinical symptoms, delaying pulmonary function decline, and improving inflammation indicators for AECOPD, with good safety. The evidence was limited by a lack of high-quality RCTs.
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28
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Miravitlles M, Verhamme K, Calverley PMA, Dreher M, Bayer V, Gardev A, de la Hoz A, Wedzicha J, Price D. A Pooled Analysis of Mortality in Patients with COPD Receiving Dual Bronchodilation with and without Additional Inhaled Corticosteroid. Int J Chron Obstruct Pulmon Dis 2022; 17:545-558. [PMID: 35309285 PMCID: PMC8924530 DOI: 10.2147/copd.s350167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/21/2022] [Indexed: 12/30/2022] Open
Abstract
Background Objective Methods Results Conclusion
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Correspondence: Marc Miravitlles, Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), P° Vall d’Hebron 119-129, Barcelona, 08035, Spain, Email
| | - Katia Verhamme
- Department of Medical Informatics, Erasmus MC, Rotterdam, the Netherlands
| | - Peter M A Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
| | - Valentina Bayer
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Jadwiga Wedzicha
- Head Respiratory Division, National Heart and Lung Institute, Imperial College London, London, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Treatment Transitions in Chronic Obstructive Pulmonary Disease: Retrospective Analyses of US and UK Healthcare Databases. Pulm Ther 2022; 8:75-93. [PMID: 35015269 PMCID: PMC8861248 DOI: 10.1007/s41030-021-00180-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/22/2021] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Previous studies have reported that more patients receive inhaled corticosteroid (ICS)-containing therapies than would be expected based on exacerbation history, suggesting overprescribing. We aimed to describe patterns of treatment switching from first (1MT) to second maintenance therapy (2MT) among COPD patients in the US and UK. METHODS We used healthcare data from the US IBM® MarketScan® and UK Clinical Practice Research Datalink databases (2015 - 2018) to assess transitions between 1MT and 2MT among COPD patients. Patients with a recorded asthma diagnosis prior to 1MT were excluded. We assessed whether prescribed treatments (long-acting muscarinic antagonists [LAMA], long-acting β2-agonists [LABA], inhaled corticosteroids [ICS], as monotherapy or in combination) were consistent with global and national recommendations for COPD, identified patient characteristics associated with treatment transitions, and evaluated treatment duration. RESULTS Overall, 7028 patients in the US and 2461 in the UK initiated 2MT within a median (IQR) 160.0 (76.0; 335.0) and 218.0 (86.0; 428.0) days after 1MT, respectively. In the US, 33.6% of patients initiating 2MT had no recorded exacerbations in the previous year, whereas 23.1% had one and 43.3% had ≥ 2. In the UK, 54.9% of patients had no recorded exacerbations in the previous year, whereas 20.9% had one and 24.2% had ≥ 2. At 2MT, most patients switched to LAMA/LABA/ICS (26.1%) or LABA/ICS (25.8%) in the US, and LAMA/LABA (39.4%) or LAMA/LABA/ICS (27.8%) in the UK; 62.2% (US) and 47.5% of patients (UK) were prescribed ICS-containing regimens. The most common treatment transition from 1MT to 2MT was LABA/ICS to LAMA/LABA/ICS (13.0%) in the US; and LAMA to LAMA/LABA (32.5%) and LAMA to LAMA/LABA/ICS (14.3%) in the UK. CONCLUSIONS At 2MT, the proportion of patients on LAMA/LABA/ICS was similar between the US and UK, but treatment pathways were different.
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30
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Cazzola M, Rogliani P, Laitano R, Calzetta L, Matera MG. Beyond Dual Bronchodilation – Triple Therapy, When and Why. Int J Chron Obstruct Pulmon Dis 2022; 17:165-180. [PMID: 35068929 PMCID: PMC8766250 DOI: 10.2147/copd.s345263] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Although pharmacological treatment of COPD is codified in different guidelines and strategy documents, there is abundant evidence of discrepancy between what they suggest and what health professionals prescribe, especially in low-risk groups where there is widespread overprescription of triple therapy. It is therefore necessary to clarify when the use of triple therapy is indicated in COPD patients and when it is preferable to maintain treatment with dual bronchodilation. In this article, we discuss our views based on our experience and what is reported in the literature and try to give answers to these two questions. The evidence generated by pivotal RCTs supports the use of triple therapy in patients who present for the first time and have severe airway obstruction, are symptomatic, have had frequent moderate or severe exacerbations in the previous year, and have peripheral eosinophilia. However, it is difficult to determine whether step-up is useful in all other cases because the available data are quite conflicting. It is likely that the inconsistency in the information generated by the various available studies may explain the prescribing behaviour of many physicians who do not adhere to recommendations of guidelines and strategies. However, it is necessary to establish whether and when the addition of an ICS to the LAMA/LABA combination is effective, to determine whether triple therapy can induce an additional clinical benefit over dual bronchodilation, irrespective of a preventive effect on COPD exacerbations, to establish its value, and to examine whether cost differences can support the use of triple therapy over combined LAMA/LABA therapy in real life.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
- Correspondence: Mario Cazzola Email
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Rossella Laitano
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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Miravitlles M, Roman-Rodríguez M, Ribera X, Ritz J, Izquierdo JL. Inhaled Corticosteroid Use Among COPD Patients in Primary Care in Spain. Int J Chron Obstruct Pulmon Dis 2022; 17:245-258. [PMID: 35115771 PMCID: PMC8800566 DOI: 10.2147/copd.s342220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Inhaled corticosteroids (ICS) are frequently used to treat chronic obstructive pulmonary disease (COPD) outside the current recommendations. Our aim was to describe ICS use in COPD patients and to identify factors associated with ICS use among COPD patients treated within primary care in Spain. Patients and Methods This was a cross-sectional, non-interventional and multicenter study of patients with COPD treated in primary care. Patient characteristics and exacerbations were described in terms of ICS use among the overall cohort, and among those with spirometry confirmed COPD (post-bronchodilator forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ratio <70%). Multivariable logistic regression was used to identify factors associated with ICS use. Results A total of 901 patients were included, of which 47.9% (n = 432) were treated with ICS. A total of 240 patients (26.6%) experienced moderate/severe exacerbations in the prior year, while 309 (34.3%) during the previous two years. History of asthma totaled 11.6% (n = 105). The most frequent phenotype was non-exacerbator (51.6%), and the proportion of patient with moderate or severe exacerbations was significantly higher among ICS treated patients compared to non-treated: 37.5% versus 16.6% during the previous year (p < 0.001), and 46.8% versus 22.8% during the previous 2-years (p < 0.001), respectively. Patient characteristics were similar among spirometry confirmed patients and the overall population. Factors significantly associated with ICS use were a history of asthma (OR = 4.39, 95% CI: 2.67–7.26), the presence of moderate or severe exacerbations in the last year (OR = 2.52, 95% CI: 1.81–3.49), followed by higher mMRC and higher CAT score. Conclusion Nearly half of patients in primary care in Spain are treated with ICS, despite most of them being non-exacerbators. History of asthma, exacerbations, and worse dyspnea and CAT scores are associated with ICS use.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Correspondence: Marc Miravitlles, Pneumology Department, Hospital Universitari Vall d’Hebron, P. Vall d’Hebron 119-129, Barcelona, ES–08035, Spain, Email
| | - Miguel Roman-Rodríguez
- Centro de Salud Dra. Teresa Pique, Mallorca, Spain
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Mallorca, Spain
| | - Xavier Ribera
- Boehringer Ingelheim España, Sant Cugat del Vallés, Barcelona, Spain
| | - John Ritz
- Syneos Health - Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - José Luis Izquierdo
- Department of Medicine and Medical Specialties, Universidad de Alcalá, Madrid, Spain
- Pneumology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
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Miravitlles M, Calle M, Molina J, Almagro P, Gómez JT, Trigueros JA, Cosío BG, Casanova C, López-Campos JL, Riesco JA, Simonet P, Rigau D, Soriano JB, Ancochea J, Soler-Cataluña JJ. Spanish COPD Guidelines (GesEPOC) 2021: Updated Pharmacological treatment of stable COPD. Arch Bronconeumol 2022; 58:69-81. [PMID: 33840553 DOI: 10.1016/j.arbres.2021.03.005] [Citation(s) in RCA: 98] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 01/16/2023]
Abstract
The Spanish COPD Guidelines (GesEPOC) were first published in 2012, and since then have undergone a series of updates incorporating new evidence on the diagnosis and treatment of COPD. GesEPOC was drawn up in partnership with scientific societies involved in the treatment of COPD and the Spanish Patients' Forum. Their recommendations are based on an evaluation of the evidence using GRADE methodology, and a narrative description of the evidence in areas in which GRADE cannot be applied. In this article, we summarize the recommendations on the pharmacological treatment of stable COPD based on 9 PICO questions. COPD treatment is a 4-step process: 1) diagnosis, 2) determination of the risk level, 3) initial and subsequent inhaled therapy, and 4) identification and management of treatable traits. For the selection of inhaled therapy, high-risk patients are divided into 3 phenotypes: non-exacerbator, eosinophilic exacerbator, and non-eosinophilic exacerbator. Some treatable traits are general and should be investigated in all patients, such as smoking or inhalation technique, while others affect severe patients in particular, such as chronic hypoxemia and chronic bronchial infection. COPD treatment is based on long-acting bronchodilators with single agents or in combination, depending on the patient's risk level. Eosinophilic exacerbators must receive inhaled corticosteroids, while non-eosinophilic exacerbators require a more detailed evaluation to choose the best therapeutic option. The new GesEPOC also includes recommendations on the withdrawal of inhaled corticosteroids and on indications for alpha-1 antitrypsin treatment. GesEPOC offers a more individualized approach to COPD treatment tailored according to the clinical characteristics of patients and their level of complexity.
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Affiliation(s)
- Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos. Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | | | - Pere Almagro
- Servicio de Medicina Interna, Hospital Universitario Mutua de Terrassa, Terrassa, España
| | | | | | - Borja G Cosío
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, España
| | - Ciro Casanova
- Servicio de Neumología-Unidad de Investigación, Hospital Universitario Nuestra Señora de La Candelaria. Universidad de La Laguna, Tenerife, España
| | - José Luis López-Campos
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, España
| | - Juan Antonio Riesco
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, España
| | - Pere Simonet
- Centro de Salud Viladecans-2, Atención Primaria Costa de Ponent-Institut Català de la Salut. Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Departament de Ciències Clíniques, Universitat Barcelona, Barcelona, España
| | - David Rigau
- Centro Cochrane Iberoamericano, Barcelona, España
| | - Joan B Soriano
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario de La Princesa. Universidad Autónoma de Madrid, Madrid, España
| | - Julio Ancochea
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario de La Princesa. Universidad Autónoma de Madrid, Madrid, España
| | - Juan José Soler-Cataluña
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Arnau de Vilanova-Lliria, Valencia, España
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Roche N, Devillier P, Berger P, Bourdin A, Dusser D, Muir JF, Martinat Y, Terrioux P, Housset B. Individual trajectory-based care for COPD: getting closer, but not there yet. ERJ Open Res 2021; 7:00451-2021. [PMID: 34912881 PMCID: PMC8666575 DOI: 10.1183/23120541.00451-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/17/2021] [Indexed: 11/05/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a main cause of death due to interplaying factors, including comorbidities that interfere with symptoms and response to therapy. It is now admitted that COPD management should be based on clinical symptoms and health status and should consider the heterogeneity of patients' phenotypes and treatable traits. This precision medicine approach involves a regular assessment of the patient's status and of the expected benefits and risks of therapy. The cornerstone of COPD pharmacological therapy is inhaled long-acting bronchodilation. In patients with persistent or worsened symptoms, factors likely to interfere with treatment efficacy include the patient's non-adherence to therapy, treatment preference, inhaler misuse and/or comorbidities, which should be systematically investigated before escalation is considered. Several comorbidities are known to impact symptoms, physical and social activity and lung function. The possible long-term side-effects of inhaled corticosteroids contrasting with their over-prescription in COPD patients justify the regular assessment of their benefits and risks, and de-escalation under close monitoring after a sufficient period of stability is to be considered. While commonly used in clinical trials, the relevance of routine blood eosinophil counts to guide therapy adjustment is not fully clear. Patients' characteristics, which define phenotypes and treatable traits and thus guide therapy, often change during life, forming the basis of the concept of clinical trajectory. The application of individual trajectory-based management of COPD in clinical practice therefore implies that the benefit:risk ratio is regularly reviewed according to the evolution of the patient's traits over time to allow optimised therapy adjustments.
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Affiliation(s)
- Nicolas Roche
- Pneumologie, Hôpital Cochin, AP-HP. Centre - Université de Paris, Institut Cochin (UMR1016), Paris, France
| | - Philippe Devillier
- UPRES EA 220, Université Versailles Saint-Quentin, Pôle des Maladies des Voies Respiratoires, Hôpital Foch, Suresnes, France
| | - Patrick Berger
- Service d'exploration fonctionnelle respiratoire, CIC 1401, CHU de Bordeaux, Pessac, France
| | - Arnaud Bourdin
- Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Daniel Dusser
- Pneumologie, Hôpital Cochin, AP-HP. Centre - Université de Paris, Institut Cochin (UMR1016), Paris, France
| | - Jean-François Muir
- Service de Pneumologie, Oncologie Thoracique et Soins Intensifs Respiratoires, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | | | | | - Bruno Housset
- Service de Pneumologie, Hôpital Intercommunal de Créteil, Créteil, France
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Papaporfyriou A, Bakakos P, Hillas G, Papaioannou AI, Loukides S. Blood eosinophils in COPD: friend or foe? Expert Rev Respir Med 2021; 16:35-41. [PMID: 34821191 DOI: 10.1080/17476348.2021.2011219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The pathogenesis of chronic obstructive pulmonary disease (COPD) is highly complex and the underlying cellular and molecular mechanisms remain poorly understood. AREAS COVERED COPD has been traditionally associated with neutrophilic inflammation of the bronchi, but in the last decade, studies have demonstrated that eosinophils may also migrate into the lower airways of patients with COPD and their increased numbers can be noticed during exacerbations as well as stable disease. In this review, we present clinical characteristics of eosinophilic COPD, as well as the role of eosinophils as a biomarker-guided therapy in COPD. A systematic research using the database of Pubmed up to February 2021 was performed. The terms we searched were eosinophilic inflammation, COPD, COPD phenotypes, COPD exacerbations, corticosteroids in COPD, and monoclonal antibodies in COPD. EXPERT OPINION Blood eosinophil levels show strong potential as a prognostic and theragnostic biomarker in the clinical management of COPD being at the moment the most reliable biomarker. The lack of a certain cutoff value of blood eosinophils as guidance for treatment with ICS and biologic therapies and the uncertainty regarding the stability of eosinophilia and eosinophilic phenotype through the course of COPD remain as unmet dilemmas and problems.
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Affiliation(s)
| | - Petros Bakakos
- 1st Respiratory Medicine Department, University of Athens Medical School Sotiria' Chest Hospital,'Athens, Greece
| | - Georgios Hillas
- 5th Pulmonary Department, "Sotiria" Chest Diseases Hospital, Athens, Greece
| | - Andriana I Papaioannou
- 2nd Respiratory Medicine Department, University of Athens Medical School 'Attikon' Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, University of Athens Medical School 'Attikon' Hospital, Athens, Greece
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Miravitlles M, Solé A, Aguilar H, Ampudia A, Costa-Samarra J, Mallén-Alberdi M, Nieves D. Economic Impact of Low Adherence to COPD Management Guidelines in Spain. Int J Chron Obstruct Pulmon Dis 2021; 16:3131-3143. [PMID: 34848952 PMCID: PMC8611727 DOI: 10.2147/copd.s322793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/20/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE The objective of this study was to assess the non-adherence level of Spanish clinical practice to guideline recommendations for the treatment of chronic obstructive pulmonary disease (COPD) and to estimate the potential impact on pharmaceutical expenditure resulting from transitioning current treatment patterns according to guidelines. METHODS A model was developed to compare current prescribing patterns with two alternative scenarios: the first aligned with the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2020) recommendations, and the second with the Spanish Guidelines for COPD (GesEPOC 2017). Current treatment practice was obtained from publications that describe treatment patterns by pulmonology departments in Spain. The economic impact between patterns was calculated from the perspective of the Spanish National Health System (NHS), considering the annual pharmacological costs of COPD inhaled maintenance therapy. Two additional analyses were performed: one that included current prescribing patterns of patients managed by pulmonology and primary care centers in Spain (published aggregated data); and another that only considered the appropriate use of inhaled corticosteroids (ICS) treatment according to guidelines. RESULTS It was estimated that 54% and 38% of patients were not treated in line with GOLD and GesEPOC recommendations, respectively, mainly due to a broader use of ICS-based therapies. Adapting treatment to recommendations could provide a potential annual cost-saving of €17,792,022 (according to GOLD) and €5,881,785 (according to GesEPOC). In scenario analysis 1, a 26% of non-adherence to GesEPOC guideline was observed with a potential annual pharmacological cost-saving of €2,707,554. In scenario analysis 2, considering only inappropriate use of ICS treatment, an annual cost-saving of €17,863,750 (according to GOLD) and €9,904,409 (according to GesEPOC) was calculated. CONCLUSION More than a third of treatments for COPD patients in Spain are not prescribed in accordance with guideline recommendations. The adaptation of clinical practice to guideline recommendations could provide important cost-savings for the Spanish NHS.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Vall d'Hebron University Hospital, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER for Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Alexandra Solé
- Market Access Department of Boehringer Ingelheim SA, Barcelona, Spain
| | - Helena Aguilar
- Medical Department of Boehringer Ingelheim SA, Barcelona, Spain
| | - Ana Ampudia
- Market Access Department of Boehringer Ingelheim SA, Barcelona, Spain
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Bartziokas K, Gogali A, Kostikas K. The Role of Blood Eosinophils in the Management of COPD: An Attempt to Answer the Important Clinical Questions. COPD 2021; 18:690-699. [PMID: 34657541 DOI: 10.1080/15412555.2021.1985989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Blood eosinophils have been proposed as a surrogate biomarker of airway eosinophilia that can be used for treatment decisions in patients with COPD, mainly for the identification of candidates for the initiation or withdrawal of therapy with inhaled corticosteroids, as well as for the identification of patients at future risk of exacerbations. In this manuscript we review the recent literature on blood eosinophils in the management of patients with COPD, in an attempt to answer the major questions that are relevant for the practicing clinician. A growing body of evidence suggests that eosinophilic COPD may constitute a separate phenotype of the disease with distinct clinical features and blood eosinophils may represent a potential candidate surrogate marker for specific COPD patients. Several points still need to be clarified, including the role of eosinophils for the identification of candidates for future COPD therapies, yet blood eosinophils plausibly represent the most dependable and promising biomarker for the precision management of COPD today.
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Affiliation(s)
| | - Athena Gogali
- Respiratory Medicine Department, University of Ioannina, Ioannina, Greece
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Abstract
Recent trials reported significant reductions in all-cause mortality with single-inhaler triple therapy for chronic obstructive pulmonary disease (COPD). However, reviews of these trials identified inconsistencies in the findings and methodological issues with the design and analysis, including the "adverse impact of inhaled corticosteroid (ICS) withdrawal rather than the addition" of the triple therapy. Indeed, ICS were discontinued in over 70% of the patients in these trials and 40% already using triple therapy, muddying the interpretation of the data. The "adaptive" clinical trial design is an efficient approach that allows continual modification of the study treatment allocation during follow-up. In this article, we propose the "adaptive selection" trial design, which applies the adaptive concept to the selection of patients into the trial by adapting the randomization choices to the treatment already used by the patients. With such a design, patients already on triple therapy would be excluded outright from trials of triple therapy effectiveness, while the others are randomly allocated to specific treatment arms according to their current treatment, avoiding issues of treatment withdrawal effects. Adaptive selection trials should be the norm for studies of COPD therapies. This approach would avoid the vexing effects of treatment withdrawal that have afflicted the recent triple therapy trials. This concept of adaptive selection has been applied in COPD to the question of whether patients can be safely de-escalated from ICS. It is time to also apply it to studies of the effectiveness of treatment escalation.
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Affiliation(s)
- Samy Suissa
- Departments of Epidemiology and Biostatistics and of Medicine, Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Martin C, Burgel PR, Roche N. Inhaled Dual Phosphodiesterase 3/4 Inhibitors for the Treatment of Patients with COPD: A Short Review. Int J Chron Obstruct Pulmon Dis 2021; 16:2363-2373. [PMID: 34429594 PMCID: PMC8378910 DOI: 10.2147/copd.s226688] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
Current pharmacological treatments for chronic obstructive pulmonary disease (COPD) are mostly limited to inhaled bronchodilators and corticosteroids. Azithromycin can contribute to exacerbation prevention. Roflumilast, a phosphodiesterase (PDE) 4 inhibitor administered orally, also prevents exacerbations in selected patients with chronic bronchitis, recurrent exacerbations, severe airflow limitation and concomitant therapy with long-acting inhaled bronchodilators. This outcome likely results from anti-inflammatory effects since PDE4 is expressed by all inflammatory cell types involved in COPD. The use of this agent is, however, limited by side-effects, particularly nausea and diarrhea. To address remaining unmet needs and enrich therapeutic options for patients with COPD, inhaled dual PDE3/4 inhibitors have been developed, with the aim of enhancing bronchodilation through PDE3 inhibition and modulating inflammation and mucus production though PDE4 inhibition, thus producing a potentially synergistic effect on airway calibre. Experimental preclinical data confirmed these effects in vitro and in animal models. At present, RPL554/ensifentrine is the only agent of this family in clinical development. It decreases sputum markers of both neutrophilic and eosinophilic inflammation in patients with COPD. Clinical Phase II trials confirmed its bronchodilator effect and demonstrated clinically meaningful symptom relief and quality of life improvements in these patients. The safety profile appears satisfactory, with less effects on heart rate and blood pressure than salbutamol and no other side effect. Altogether, these data suggest that ensifentrine could have a role in COPD management, especially in addition to inhaled long-acting bronchodilators with or without corticosteroids since experimental studies suggest potentiation of ensifentrine effects by these agents. However, results from ongoing and future Phase III studies are needed to confirm both beneficial effects and favourable safety profile on a larger scale and assess other outcomes including exacerbations, lung function decline, comorbidities and mortality.
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Affiliation(s)
- Clémence Martin
- AP-HP Centre, Hôpital Cochin, Service de Pneumologie, Paris, France.,Université de Paris, Institut Cochin, INSERM UMR 1016, Paris, France
| | - Pierre-Régis Burgel
- AP-HP Centre, Hôpital Cochin, Service de Pneumologie, Paris, France.,Université de Paris, Institut Cochin, INSERM UMR 1016, Paris, France
| | - Nicolas Roche
- AP-HP Centre, Hôpital Cochin, Service de Pneumologie, Paris, France.,Université de Paris, Institut Cochin, INSERM UMR 1016, Paris, France
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Sivapalan P, Jensen JU. Biomarkers in Chronic Obstructive Pulmonary Disease: Emerging Roles of Eosinophils and Procalcitonin. J Innate Immun 2021; 14:89-97. [PMID: 34428766 PMCID: PMC9082212 DOI: 10.1159/000517161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/22/2021] [Indexed: 11/19/2022] Open
Abstract
Antibiotics can improve the prognosis in patients with exacerbation of chronic obstructive pulmonary disease. However, the overuse of antibiotics can carry serious adverse effects for patients (gastrointestinal infections) and for society (bacterial resistance). Likewise, systemic corticosteroids may also help these patients, but also carries severe adverse effects like osteoporosis, muscle loss, and diabetes, in many patients. Whenever safe methods exist to reduce these two treatment modalities, they should be implemented. The blood biomarkers procalcitonin and the fraction of leukocytes known as eosinophil granulocytes have been proven in randomized controlled trials (RCTs), to effectively, significantly, and substantially assist in reducing the use of these two potent, yet toxic medication types. In this review, the background and main clinical results are discussed, explaining the rationale for biomarker-guided clinical decisions. Also, the main expected effects, their sizes, and importantly the limitations to such a strategy are described. Clinical evidence is prioritized with main weight on RCTs and meta-analyses of these and regarding outcomes, and focus is set on the safety of such a biomarker-guided strategy, as well as the effects on medicine reduction. In an epoch of increasing demands to physicians from patients and politicians to cure and reduce symptoms, the Hippocratic phrase of "primum non nocere" or "first, do no harm" seems more than ever of contemporary importance.
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Affiliation(s)
- Pradeesh Sivapalan
- Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jens-Ulrik Jensen
- Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Pullen R, Miravitlles M, Sharma A, Singh D, Martinez F, Hurst JR, Alves L, Dransfield M, Chen R, Muro S, Winders T, Blango C, Muellerova H, Trudo F, Dorinsky P, Alacqua M, Morris T, Carter V, Couper A, Jones R, Kostikas K, Murray R, Price DB. CONQUEST Quality Standards: For the Collaboration on Quality Improvement Initiative for Achieving Excellence in Standards of COPD Care. Int J Chron Obstruct Pulmon Dis 2021; 16:2301-2322. [PMID: 34413639 PMCID: PMC8370848 DOI: 10.2147/copd.s313498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/30/2021] [Indexed: 12/17/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) are managed predominantly in primary care. However, key opportunities to optimize treatment are often not realized due to unrecognized disease and delayed implementation of appropriate interventions for both diagnosed and undiagnosed individuals. The COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST) is the first-of-its-kind, collaborative, interventional COPD registry. It comprises an integrated quality improvement program focusing on patients (diagnosed and undiagnosed) at a modifiable and higher risk of COPD exacerbations. The first step in CONQUEST was the development of quality standards (QS). The QS will be imbedded in routine primary and secondary care, and are designed to drive patient-centered, targeted, risk-based assessment and management optimization. Our aim is to provide an overview of the CONQUEST QS, including how they were developed, as well as the rationale for, and evidence to support, their inclusion in healthcare systems. Methods The QS were developed (between November 2019 and December 2020) by the CONQUEST Global Steering Committee, including 11 internationally recognized experts with a specialty and research focus in COPD. The process included an extensive literature review, generation of QS draft wording, three iterative rounds of review, and consensus. Results Four QS were developed: 1) identification of COPD target population, 2) assessment of disease and quantification of future risk, 3) non-pharmacological and pharmacological intervention, and 4) appropriate follow-up. Each QS is followed by a rationale statement and a summary of current guidelines and research evidence relating to the standard and its components. Conclusion The CONQUEST QS represent an important step in our aim to improve care for patients with COPD in primary and secondary care. They will help to transform the patient journey, by encouraging early intervention to identify, assess, optimally manage and followup COPD patients with modifiable high risk of future exacerbations.
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Affiliation(s)
- Rachel Pullen
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Optimum Patient Care, Cambridge, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Anita Sharma
- Platinum Medical Centre, Chermside, QLD, Australia
| | - Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fernando Martinez
- New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Luis Alves
- EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal.,Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - Mark Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rongchang Chen
- Key Laboratory of Respiratory Disease of Shenzhen, Shenzhen Institute of Respiratory Disease, Shenzhen People's Hospital (Second Affiliated Hospital of Jinan University, First Affiliated Hospital of South University of Science and Technology of China), Shenzhen, People's Republic of China
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Nara, Japan
| | - Tonya Winders
- USA & Global Allergy & Airways Patient Platform, Vienna, Austria
| | - Christopher Blango
- Janssen Pharmaceutical Companies of Johnson & Johnson, Philadelphia, PA, USA
| | | | | | | | | | | | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Optimum Patient Care, Cambridge, UK
| | - Amy Couper
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Optimum Patient Care, Cambridge, UK
| | - Rupert Jones
- Research and Knowledge Exchange, Plymouth Marjon University, Plymouth, UK
| | - Konstantinos Kostikas
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Ruth Murray
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Optimum Patient Care, Cambridge, UK.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Nigro SC, Sobieraj DM. Budesonide/Glycopyrrolate/Formoterol Fumarate Co-suspension Metered Dose Inhaler: A Triple Therapy for the Treatment of Chronic Obstructive Pulmonary Disease. Ann Pharmacother 2021; 56:582-591. [PMID: 34382422 DOI: 10.1177/10600280211038353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review current evidence on the use of a fixed-dose combination (FDC) of budesonide/glycopyrrolate/formoterol fumarate (BGFF) triple therapy delivered via metered dose inhaler (MDI) in patients with chronic obstructive pulmonary disease (COPD) and offer clinical practice insights. DATA SOURCES We used PubMed to conduct the literature search from 1946 through June 30, 2021, using budesonide, glycopyrrolate or glycopyrronium, and formoterol. STUDY SELECTION AND EXTRACTION We included clinical trials in patients with COPD along with pharmacokinetic or pharmacodynamic studies. DATA SYNTHESIS In all, 19 citations were included. BGFF MDI reduces the risk of exacerbations regardless of exacerbation history compared with dual bronchodilators or inhaled corticosteroid/long-acting β-agonist. Rescue inhaler use decreased, and patient-reported outcomes of symptoms and well-being improved with triple therapy. Mortality was decreased with the higher-dose BGFF MDI in comparison to dual bronchodilator therapy. Dysphonia and candidiasis were more common with BGFF MDI compared with dual bronchodilators, as was pneumonia. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE BGFF MDI is the second FDC triple therapy approved for COPD treatment. BGFF MDI improves important patient outcomes in COPD, including exacerbation risk. The unique co-suspension technology allows delivery of 3 active ingredients in 1 inhaler, a potential benefit to overcome adherence and technique-related barriers. These benefits must be gently weighed against the increased risk of pneumonia. CONCLUSION The findings from phase 3 trials support the efficacy and safety of triple therapy in COPD. Future studies are needed to confirm potential mortality benefit and the role of triple therapy in patients without an exacerbation history.
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Katzenberg G, Deacon A, Aigbirior J, Vestbo J. Management of chronic obstructive pulmonary disease. Br J Hosp Med (Lond) 2021; 82:1-10. [PMID: 34338012 DOI: 10.12968/hmed.2020.0561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chronic obstructive pulmonary disease is a prevalent condition in the UK, associated with high morbidity and mortality. Hospital physicians manage a significant portion of acute chronic obstructive pulmonary disease admissions to hospital and readmissions after discharge. Optimal management of exacerbations requires controlled oxygen therapy and ventilatory support where necessary, and careful administration of bronchodilators, steroids and antibiotics. Holistic care for these patients includes nutritional supplementation and palliative support for those with advanced disease. To reduce the chance of readmission, chronic obstructive pulmonary disease care bundles can be used, along with a review of inhaled and oral therapies. Where available, hospital-at-home discharge schemes can safely facilitate early discharge. Most importantly, high quality evidence-based smoking cessation support must be offered to smokers. Exercise improves the physiological and psychological condition of people with chronic obstructive pulmonary disease and should be encouraged, with referral to a pulmonary rehabilitation service if available.
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Affiliation(s)
- Gideon Katzenberg
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Science Centre, Manchester, UK
| | - Andrew Deacon
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Science Centre, Manchester, UK
| | - Joshua Aigbirior
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Science Centre, Manchester, UK
| | - Jørgen Vestbo
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Science Centre, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
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Mekov E, Nuñez A, Sin DD, Ichinose M, Rhee CK, Maselli DJ, Coté A, Suppli Ulrik C, Maltais F, Anzueto A, Miravitlles M. Update on Asthma-COPD Overlap (ACO): A Narrative Review. Int J Chron Obstruct Pulmon Dis 2021; 16:1783-1799. [PMID: 34168440 PMCID: PMC8216660 DOI: 10.2147/copd.s312560] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/20/2021] [Indexed: 12/14/2022] Open
Abstract
Although chronic obstructive pulmonary disease (COPD) and asthma are well-characterized diseases, they can coexist in a given patient. The term asthma-COPD overlap (ACO) was introduced to describe patients that have clinical features of both diseases and may represent around 25% of COPD patients and around 20% of asthma patients. Despite the increasing interest in ACO, there are still substantial controversies regarding its definition and its position within clinical guidelines for patients with obstructive lung disease. In general, most definitions indicate that ACO patients must present with non-reversible airflow limitation, significant exposure to smoking or other noxious particles or gases, together with features of asthma. In patients with a primary diagnosis of COPD, the identification of ACO has therapeutic implication because the asthmatic component should be treated with inhaled corticosteroids and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. This manuscript aims to summarize the current state-of-the-art of ACO. The definitions, prevalence, and clinical manifestations will be reviewed and some innovative aspects, such as genetics, epigenetics, and biomarkers will be addressed. Lastly, the management and prognosis will be outlined as well as the position of ACO in the COPD and asthma guidelines.
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Affiliation(s)
- Evgeni Mekov
- Department of Occupational Diseases, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Alexa Nuñez
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Don D Sin
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Department of Medicine (Respiratory Division), University of British Columbia, Vancouver, BC, Canada
| | | | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Diego Jose Maselli
- Division of Pulmonary Diseases & Critical Care, University of Texas Health, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Andréanne Coté
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Charlotte Suppli Ulrik
- Department of Pulmonary Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - François Maltais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Antonio Anzueto
- Division of Pulmonary Diseases & Critical Care, University of Texas Health, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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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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Yong SJ. Diseased lungs may hinder COVID-19 development: A possible reason for the low prevalence of COPD in COVID-19 patients. Med Hypotheses 2021; 153:110628. [PMID: 34139599 PMCID: PMC8188770 DOI: 10.1016/j.mehy.2021.110628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
Presently, it remains unclear why the prevalence of lung diseases, namely chronic obstructive pulmonary disease (COPD), is much lower than other medical comorbidities and the general population among patients with coronavirus disease 2019 (COVID-19). If COVID-19 is a respiratory disease, why is COPD not the leading risk factor for contracting COVID-19? The same odd phenomenon was also observed with other pathogenic human coronaviruses causing severe acute respiratory distress syndrome (SARS) and Middle East respiratory syndrome (MERS), but not other respiratory viral infections such as influenza and respiratory syncytial viruses. One commonly proposed reason for the low COPD rates among COVID-19 patients is the usage of inhaled corticosteroids or bronchodilators that may protect against COVID-19. However, another possible reason not discussed elsewhere is that lungs in a diseased state may not be conducive for the severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) to establish COVID-19. For one, COPD causes mucous plugging in large and small airways, which may hinder SARS-CoV-2 from reaching deeper parts of the lungs (i.e., alveoli). Thus, SARS-CoV-2 may only localize to the upper respiratory tract of persons with COPD, causing mild or asymptomatic infections requiring no hospital attention. Even if SARS-CoV-2 reaches the alveoli, cells therein are probably under a heavy burden of endoplasmic reticulum (ER) stress and extensively damaged where it may not support efficient viral replication. As a result, limited SARS-CoV-2 virions would be produced in diseased lungs, preventing the development of COVID-19.
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Affiliation(s)
- Shin Jie Yong
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Selangor, Malaysia.
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Tsiligianni I, Hoeines KJ, Jensen C, Kocks JWH, Ställberg B, Vicente C, Peché R. Towards Rational Prescription of Common Inhaler Medication in the Multimorbid COPD Patient. Int J Chron Obstruct Pulmon Dis 2021; 16:1315-1327. [PMID: 34012259 PMCID: PMC8127323 DOI: 10.2147/copd.s298345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/31/2021] [Indexed: 11/23/2022] Open
Abstract
COPD is a chronic disease, typically accompanied by multiple comorbid conditions. The need to apply several, and sometimes conflicting, disease-specific treatment guidelines, complicates the management of individual patients. Moreover, national and international recommendations evolve rapidly but provide limited guidance on the integrated approach in the multimorbid patient. Particularly bothersome is the fact that the presence of comorbidities may deteriorate the course of COPD, and inversely COPD may affect the outcome of the comorbid diseases. In addition, some effects of commonly prescribed COPD inhaler medications, including beta2-agonists, long-acting antimuscarinics and especially inhaled corticosteroids, mimic or worsen COPD-related comorbidities. Therefore, the authors combined their perspectives to formulate advice that may help physicians to improve COPD patient care in daily practice when comorbidities are present. Diabetes, atrial fibrillation, osteoporosis/fractures, infections (pneumonia and tuberculosis) and asthma were identified as areas where practicing clinicians should give special attention to the risk-benefit ratio of the inhaled medication. Overall, the presence of multimorbidity in a COPD patient should act as a signal to carefully reconsider the treatment choices.
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Affiliation(s)
| | | | | | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Rudi Peché
- Department of Pneumology, ISPPC, CHU Charleroi, Charleroi, Belgium
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Zysman M, Ribeiro Baptista B, Soumagne T, Marques da Silva V, Martin C, Thibault de Menonville C, Boyer L, Degano B, Morelot Panzini C, Burgel PR, Perez T, Bourdin A, Raherison C, Pégliasco H, Piperno D, Zanetti C, Morel H, Delclaux B, Delafosse C, Lorenzo A, Housset B, Chabot F, Devillier P, Deslée G, Roche N. [Pharmacological treatment optimisation in patients with stale COPD. Position of the French-language Respiratory Society. 2021 Update]. Rev Mal Respir 2021; 38:539-561. [PMID: 33985869 DOI: 10.1016/j.rmr.2021.02.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 02/21/2021] [Indexed: 01/19/2023]
Affiliation(s)
- M Zysman
- Université Bordeaux, centre de recherche cardiothoracique de Bordeaux, U1045, CIC 1401, 33604 Pessac, France; Service des maladies respiratoires, CHU Bordeaux, Bordeaux, France.
| | - B Ribeiro Baptista
- Université Paris-Est, UMR S955, UPEC, 94000 Créteil, France; Département de pneumologie, CHRU Nancy, université de Lorraine, Inserm, U1116, université de Lorraine, Nancy/Vandœuvre-lès-Nancy, France
| | - T Soumagne
- Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHU de Besançon, Besançon, France
| | | | - C Martin
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | | | - L Boyer
- Université Paris-Est, UMR S955, UPEC, 94000 Créteil, France; Département de physiologie-explorations fonctionnelles, AP-HP, hôpital Henri-Mondor, Paris, France
| | - B Degano
- Service hospitalier universitaire pneumologie physiologie, pôle thorax et vaisseaux, CHU Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - C Morelot Panzini
- Sorbonne Université, AP-HP, Service de Pneumologie, Médecine Intensive et Réanimation, Pitié-Salpêtrière Hospital, Paris, France
| | - P R Burgel
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | - T Perez
- Service de pneumologie, CHU Lille, institut Pasteur de Lille, U1019, UMR9017, centre d'infection et d'immunité de Lille (CIIL), Lille, France
| | - A Bourdin
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France; Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, Montpellier, France
| | - C Raherison
- Service des maladies respiratoires, CHU Bordeaux, Bordeaux, France; Bordeaux Population Health Research Center, université Bordeaux, INSERM, Team EPICENE, UMR 1219, Bordeaux, France
| | - H Pégliasco
- Service de pneumologie, hôpital européen, Marseille, France
| | | | - C Zanetti
- Cabinet de pneumologie, 62300 Lens, France
| | - H Morel
- Service de pneumologie d'allergologie et d'oncologie thoracique, CHR d'Orléans, 45067 Orléans, France
| | - B Delclaux
- Service de pneumologie, centre hospitalier de Troyes, 10003 Troyes, France
| | - C Delafosse
- Centre hospitaliser Simone-Veil, 95602 Eaubonne, France
| | - A Lorenzo
- Médecine Sorbonne université, département de médecine générale, Paris, France
| | - B Housset
- Département de pneumologie, CHI de Créteil, University Paris Est Créteil, Créteil, France
| | - F Chabot
- Département de pneumologie, CHRU Nancy, université de Lorraine, Inserm, U1116, université de Lorraine, Nancy/Vandœuvre-lès-Nancy, France
| | - P Devillier
- Department of Airway Diseases, VIM-Suresnes, UMR0892, Foch Hospital, Paris-Saclay University, Suresnes, France
| | - G Deslée
- Service de pneumologie, Inserm U1250, CHU Reims, université Reims Champagne Ardenne, Reims, France
| | - N Roche
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
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Effectiveness and Safety of COPD Maintenance Therapy with Tiotropium/Olodaterol versus LABA/ICS in a US Claims Database. Adv Ther 2021; 38:2249-2270. [PMID: 33721209 PMCID: PMC8107175 DOI: 10.1007/s12325-021-01646-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/02/2021] [Indexed: 11/18/2022]
Abstract
Introduction In patients with chronic obstructive pulmonary disease (COPD), treatment with long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) combination therapy significantly improves lung function versus LABA/inhaled corticosteroid (ICS). To investigate whether LAMA/LABA could provide better clinical outcomes than LABA/ICS, this non-interventional database study assessed the risk of COPD exacerbations, pneumonia, and escalation to triple therapy in patients with COPD initiating maintenance therapy with tiotropium/olodaterol versus any LABA/ICS combination. Methods Administrative healthcare claims and laboratory results data from the US HealthCore Integrated Research Databasesm were evaluated for patients with COPD initiating tiotropium/olodaterol versus LABA/ICS treatment (January 2013–March 2019). Patients were aged at least 40 years with a diagnosis of COPD (but not asthma) at cohort entry. A Cox proportional hazard regression model was used (as-treated analysis) to assess risk of COPD exacerbation, community-acquired pneumonia, and escalation to triple therapy, both individually and as a combined risk of any one of these events. Potential imbalance of confounding factors between cohorts was handled using fine stratification, reweighting, and trimming by exposure propensity score (high-dimensional); subgroup analyses were conducted on the basis of blood eosinophil levels and exacerbation history. Results The total population consisted of 61,985 patients (tiotropium/olodaterol n = 2684; LABA/ICS n = 59,301); after reweighting, the total was 42,953 patients (tiotropium/olodaterol n = 2600; LABA/ICS n = 40,353; mean age 65 years; female 54.5%). Patients treated with tiotropium/olodaterol versus LABA/ICS experienced a reduction in the risk of COPD exacerbations (adjusted hazard ratio 0.76 [95% confidence interval 0.68, 0.85]), pneumonia (0.74 [0.57, 0.97]), escalation to triple therapy (0.22 [0.19, 0.26]), and any one of these events (0.45 [0.41, 0.49]); the combined risk was similar irrespective of baseline eosinophils and exacerbation history. Conclusions In patients with COPD, tiotropium/olodaterol was associated with a lower risk of COPD exacerbations, pneumonia, and escalation to triple therapy versus LABA/ICS, both individually and in combination; the combined risk was reduced irrespective of baseline eosinophils or exacerbation history. Trial Registration ClinicalTrials.gov identifier, NCT04138758 (registered 23 October 2019). Graphic Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01646-5.
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[Chronic obstructive pulmonary disease: the right treatment for the right patient]. Internist (Berl) 2021; 62:679-685. [PMID: 33860810 PMCID: PMC8217063 DOI: 10.1007/s00108-021-01021-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/26/2022]
Abstract
In den vergangenen Jahren wurden auf dem Gebiet der chronisch-obstruktiven Lungenerkrankung (COPD) große Therapiestudien publiziert, die 2020 um mehrere Post-hoc-Analysen ergänzt wurden. Die neuen Erkenntnisse flossen in das Update des Global-Initiative-for-Chronic-Obstructive-Lung-Disease(GOLD)-Report 2021 ein. Im vorliegenden Beitrag werden die aktualisierten Grundlagen und Empfehlungen zur Therapie der COPD beschrieben. Dabei wird auf die Indikationen von inhalativen Kortikosteroiden (ICS), lang wirksamen Muskarinantagonisten (LAMA) und/oder lang wirksamen β‑Mimetika (LABA) eingegangen. Die Therapie der COPD wird der des Asthma bronchiale gegenübergestellt. Diskutiert wird auch, wie sich eine gleichzeitig bestehende Asthmakomponente auf die Behandlungsstrategie bei COPD auswirkt. Ein Schwerpunkt des Beitrags liegt auf der Triple-Therapie mit LAMA, LABA und ICS. In diesem Zusammenhang werden die Studienlage und die Indikationen beschrieben. Die Bronchodilatation bleibt weiterhin die Grundlage der COPD-Therapie. Für Patienten mit gehäuften Exazerbationen bedeutet eine Triple-Therapie mit LAMA + LABA + ICS einen Mortalitätsvorteil. Weitere Analysen oder Studien sollen klären, ob dieser Effekt für spezifische Subgruppen stärker ausgeprägt ist.
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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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