Inhaled corticosteroids in COPD: friend or foe?

Exploring a novel approach to COPD treatment: benralizumab effect in an ex vivo 3-D model

BACKGROUND

Recent evidence supports the hypothesis that eosinophilic inflammation is a relevant component in the pathogenesis of COPD.

OBJECTIVE

The current study aimed to assess the effects of Benralizumab, on ex vivo "COPD smoke-induced" bronchial mucosa equivalents.

METHODS

Three-dimensional (3D) composite ex-vivo bronchial mucosa are used to study the mechanisms of repair, regeneration and differentiation within the epithelial-mesenchymal trophic unit (EMTU). After a one month incubation in growth medium and basal membrane extracts, epithelial cells differentiate into ciliated and mucous-producing cells, and mesenchymal cells into fibroblasts. This culture model is induced to express an inflammatory phenotype through exposure to cigarette smoke extracts. Eosinophils (Eos) are placed underneath the connective layers, whereas monocytes are activated and monocyte conditioned medium (MCM) is collected. The inflammatory cells established a cross-talk with resident cells by cytokine productions. The protocol included four experimental conditions: untreated control (K), Eos only (EO), Eos + MCM (EOMO), Eos + MCM + Benralizumab (EMB).

RESULTS

Cytokine concentrations at basal and apical side were analyzed. At basal side, IL (interleukin)-5 significantly increased after the addition of eosinophils and monocytes, and decreased after the introduction of Benralizumab to the culture (after 14 days of treatment, K group: 14.6 ± 3.2 pg/mL; EO group: 13.9 ± 4.2 pg/mL; EOMO group: 35.7 ± 5.9 pg/mL; EMB group: 14.04 ± 4 pg/mL, p < 0.005). The reduction persisted for the subsequent 14 days. IL-6 and IL-15 concentration was high in EOMO groups while EMB groups had a reduction in both interleukins concentration.

CONCLUSION

The findings described lead to speculate on a potential action of benralizumab on alternative inflammatory targets.

Adherence to Pharmacological Management Guidelines for Stable Chronic Obstructive Lung Disease

BACKGROUND

This study evaluated adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and Korean guidelines in the prescription patterns of respiratory specialists for stable chronic obstructive pulmonary disease (COPD) management.

METHODS

Data were collected on medications from 2011 to 2022 using the Korea COPD Subtype Study (KOCOSS) cohort. Patients were divided into two groups: those registered before and after 2019, and we analyzed the percentage of patients meeting the recommended treatment criteria established by each guideline.

RESULTS

Among 3,477 patients, 85.6% received pharmacological therapy, and 81.6% utilized inhaled medications. Compared to patients enrolled before 2019, there was an increase in inhaler prescriptions among those registered after 2019 (79.7% vs. 86.7%), with dual bronchodilators being the predominant therapy prescribed. Of the patients receiving treatment, 56.9% adhered to the Korean 2018 guideline. Compliance with the GOLD 2019 and GOLD 2023 guidelines was observed in 31.3% and 28.0% of cases, respectively. When analyzing inhaler prescription patterns according to both subgroups and considering the Korean 2018, GOLD 2019, and GOLD 2023 guidelines concurrently, the adherence rates were as follows: (56.6%, 37.8%, 24.0%) and (57.7%, 14.0%, 38.6%).

CONCLUSION

Adherence rates were higher for the Korean guideline compared to the GOLD recommendations. Furthermore, alignment with both the Korean 2018 and GOLD 2023 guidelines increased among patients enrolled after 2019, compared to those registered earlier. These findings suggest that physicians are modifying their therapeutic strategies to align with both domestic and recent international guidelines.

Predicting postoperative pulmonary infection in elderly patients undergoing major surgery: a study based on logistic regression and machine learning models

BACKGROUND

Postoperative pulmonary infection (POI) is strongly associated with a poor prognosis and has a high incidence in elderly patients undergoing major surgery. Machine learning (ML) algorithms are increasingly being used in medicine, but the predictive role of logistic regression (LR) and ML algorithms for POI in high-risk populations remains unclear.

METHODS

We conducted a retrospective cohort study of older adults undergoing major surgery over a period of six years. The included patients were randomly divided into training and validation sets at a ratio of 7:3. The features selected by the least absolute shrinkage and selection operator regression algorithm were used as the input variables of the ML and LR models. The random forest of multiple interpretable methods was used to interpret the ML models.

RESULTS

Of the 9481 older adults in our study, 951 developed POI. Among the different algorithms, LR performed the best with an AUC of 0.80, whereas the decision tree performed the worst with an AUC of 0.75. Furthermore, the LR model outperformed the other ML models in terms of accuracy (88.22%), specificity (90.29%), precision (44.42%), and F1 score (54.25%). Despite employing four interpretable methods for RF analysis, there existed a certain degree of inconsistency in the results. Finally, to facilitate clinical application, we established a web-friendly version of the nomogram based on the LR algorithm; In addition, patients were divided into three significantly distinct risk intervals in predicting POI.

CONCLUSIONS

Compared with popular ML algorithms, LR was more effective at predicting POI in older patients undergoing major surgery. The constructed nomogram could identify high-risk elderly patients and facilitate perioperative management planning.

TRIAL REGISTRATION

The study was retrospectively registered (NCT06491459).

Effect of benralizumab treatment on the airway microbiome in COPD

Background

One-third of patients with COPD have an eosinophilic inflammatory phenotype. Benralizumab is an afucosylated humanised monoclonal antibody that targets the interleukin-5 receptor α subunit, leading to rapid and near-complete eosinophil depletion via antibody-dependent cellular cytotoxicity. We hypothesised that benralizumab-targeted immune modulation could have an impact on the airway microbiome in COPD. The objective of the present study was to investigate the effect of benralizumab treatment on inflammation and the sputum microbiome in COPD.

Methods

Sputum samples from 94 COPD patients enrolled to the GALATHEA trial (NCT02138916) and randomised to receive placebo (33), benralizumab at 100 mg (29) or 30 mg (32) over 52 weeks were analysed at baseline, week 24 and at end of treatment (week 56). Sputum microbiota taxonomic profiles and diversity indices, generated from paired-end Illumina sequencing targeting the 16S rRNA gene, were used for comparative analyses. Linear mixed model analyses were applied to blood and sputum cell counts and eosinophil mediators for within- and between-treatment group analyses.

Results

Participants treated with 100 and 30 mg benralizumab, respectively, showed a significant reduction from baseline in both blood and sputum eosinophil counts (blood: p=1.2e-10 and p=8.8e-10; sputum p=0.03 and p=0.004) and eosinophil-derived serum mediators (eosinophil cationic protein: p<3e-09 and p<2e-08; eosinophil-derived neurotoxin: p<8e-12 and p<2e-09). No significant changes in the composition or diversity of the sputum microbiome were observed.

Conclusions

In this study, the airway microbiome measured in sputum was unaffected by a targeted reduction of eosinophilic inflammation with benralizumab treatment.

Risk Factors of FEV₁/FVC Decline in COPD Patients

BACKGROUND

Factors influencing the decline in forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) for chronic obstructive pulmonary disease (COPD) progression remain uncertain. We aimed to identify risk factors associated with rapid FEV₁/FVC decline in patients with COPD.

METHODS

This multi-center observational study was conducted from January 2012 to December 2022. Eligible patients were monitored with symptoms, spirometric tests, and treatment patterns over 3 years. Rapid FEV₁/FVC decliners were defined as the quartile of patients exhibiting the highest annualized percentage decline in FEV₁/FVC.

RESULTS

Among 1,725 patients, 435 exhibited rapid FEV₁/FVC decline, with an annual change of -2.5%p (interquartile range, -3.5 to -2.0). Rapid FEV₁/FVC decliners exhibited lower body mass index (BMI), higher smoking rates, elevated post-bronchodilator (BD) FEV₁, higher post-BD FEV₁/FVC, and a lower prevalence of Staging of Airflow Obstruction by Ratio (STAR) stage IV. Rapid FEV₁/FVC decline was not linked to the annual exacerbation rate, but there was an association with symptom deterioration and FEV₁ decline. In multivariable analyses, low BMI, current smoking, increased modified Medical Research Council dyspnoea score, low post-BD FEV₁, low STAR stage, high forced mid-expiratory flow (FEF25-75%), accelerated FEV₁ decline, and not initiating dual BD therapy were identified as independent risk factors for rapid FEV₁/FVC decline.

CONCLUSION

We identified the risk factors for rapid FEV₁/FVC decline, including BMI, smoking, symptoms deterioration, FEV₁ decline, and adherence to standard inhaler treatment. Our findings underscore the potential benefits of maintaining consistent use of long-acting beta-agonist/long-acting muscarinic antagonist even in the presence of worsening symptoms, in attenuating FEV₁/FVC decline.

Inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review and meta-analysis on mortality protection - making a long story short

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide, primarily due to persistent airflow limitation from tobacco and biomass smoke exposure. While inhaled corticosteroids (ICS) combined with long-acting bronchodilators, namely long-acting β2-adrenoreceptor agonists (LABA) and long-acting muscarinic antagonists (LAMA), are recommended for symptom control and exacerbation reduction, their effect on mortality remains uncertain. Recent randomized controlled trials (RCTs) suggest potential mortality benefits with triple ICS/LABA/LAMA therapy, though findings are not definitive.

METHODS

We conducted a systematic review and network meta-analysis (NMA) to evaluate the impact of ICS-containing therapies on all-cause mortality in COPD. Searches were performed across ClinicalTrials.gov, Cochrane Library, EMBASE, MEDLINE, and SCOPUS, focusing on RCTs measuring mortality as an efficacy outcome.

RESULTS

A total of 42,784 COPD patients from five high-quality studies were included. Pairwise meta-analysis showed a significant reduction in all-cause mortality with ICS-containing therapies (RR 0.80, 95% CI 0.68-0.95), particularly with ICS/LABA and ICS/LABA/LAMA combinations. The NMA ranked ICS/LABA/LAMA as the most effective treatment (SUCRA 0.89).

CONCLUSIONS

This study provides compelling evidence that ICS-containing therapies, particularly triple therapy, significantly reduce all-cause mortality in COPD patients. Future research should identify patient subgroups most likely to benefit while minimizing adverse effects.

REGISTRATION

PROSPERO registration ID: CRD42024607568.

Prevalence and Clinical Outcomes of Eosinophilic COPD in a Saudi Population: A Retrospective Study

Objective

This study assessed the prevalence of eosinophilic chronic obstructive pulmonary disease (COPD) among a selected Saudi population and examined its correlation with baseline characteristics, clinical outcomes, exacerbation risk, and current management.

Materials and Methods

This retrospective single-center study was conducted over a 2-year period. The patients were divided into two groups based on the blood eosinophil count at the time of diagnosis: eosinophilic COPD (≥300 cells/μl) and non-eosinophilic COPD (<300 cells/μl) groups.

Results

Overall, 156 patients were included, of which 76 (48.7%) and 80 (51.3%) patients belonged to the eosinophilic and non-eosinophilic COPD groups, respectively. There were no significant differences between both groups regarding age, gender, smoking status, coexisting morbidities, FEV1, FEV1/FVC, and COPD severity (for all, P >0.05). Besides, there were no significant differences between both groups regarding the frequency and numbers of exacerbations, emergency room visits, in-patient hospitalizations, and intensive care unit admissions (for all, P >0.05). Among patients with eosinophilic COPD, 64 patients (84.2%) were correctly receiving the triple therapy of long-acting β2 agonists + long-acting muscarinic antagonist + inhaled corticosteroids, whereas 4 patients (5.26%) were incorrectly receiving the dual therapy of long-acting β2 agonists + inhaled corticosteroids. Univariate regression analyses revealed that heart failure, GOLD 3 severity, use of triple therapy, and use of non-invasive ventilation were significantly correlated with a higher risk of COPD exacerbation. Conversely, higher FEV1 was significantly correlated with lower risk of COPD exacerbation. The eosinophilic COPD phenotype was not found to be a significant independent variable of COPD exacerbation.

Conclusion

This study found that among Saudi patients with COPD, there was no clinically important relationship between baseline blood eosinophil count and the rate of exacerbation.

Measuring exhaled nitric oxide in COPD: from theoretical consideration to practical views

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is traditionally perceived as Th1-inflammation, but some patients have Th2-inflammation. A high fraction of exhaled nitric oxide (FENO) is seen in asthma with Th2-inflammation, justifying FENO as a point-of-care biomarker. The use of FENO in COPD is much less frequent. We aimed to review the evidence in favor of FENO measurement in COPD and discuss its potential usefulness in clinical settings.

AREAS COVERED

This review covers nitric oxide production in the airways and FENO measurements in COPD patients during stable conditions and acute exacerbation. It discusses why COPD patients may have both low and high FENO levels and the potential clinical utility of FENO.

EXPERT OPINION

There is good evidence that FENO increases with an exacerbation irrespective of the initial low or high baseline value. However, there is insufficient evidence to establish a fixed cutoff value for elevated FENO in COPD today. Instead, a personal baseline FENO level should be established when the patient is in a stable phase of the disease, which will subsequently set high and low FENO levels in a personalized manner. In the future, home monitoring of FENO could help identify exacerbations early, allowing proper action to be taken.

Inhaled corticosteroid increased the risk of adrenal insufficiency in patients with chronic airway diseases: a nationwide population-based study

Inhaled corticosteroids (ICS) are commonly used for airway disease, but concerns about adrenal insufficiency (AI) have arisen. This retrospective observational study investigated the link between ICS use and AI risk using data from the National Health Insurance Service-National Sample Cohort, analyzing 66,631 patients with COPD (Korean Standard Classification of Diseases [KCD] codes J42-J44) or asthma (KCD codes J45-J46). ICS use, daily dosage, and AI cases (hospitalization or ≥ 2 outpatient visits with KCD code E27) were identified via diagnostic codes. Cox proportional hazard survival analysis and inverse probability of treatment weighting (IPTW) addressed baseline differences between ICS and non-ICS users. In total 66,631 patients, the mean age was 57.3 years, 42.6% were male, and 42.2% had a Charlson comorbidity index (CCI) of 2 or higher. Among the patients, 15.5% used ICS, with a mean daily dose of 404.2 µg/day. The incidence of AI was higher in ICS users (1.69 per 1000) than in non-users (0.54 per 1000). ICS use independently increased AI risk (HR: 3.06, 95% CI: 1.82-5.14, p < 0.001). Each 100 µg/day increase in ICS was associated with a 3% increase in AI incidence (HR: 1.03, 95% CI: 1.02-1.04, p < 0.001). Quartile analysis indicated a significant AI risk increase across all ICS dosage quartiles compared with non-users. Subgroup analysis showed consistent associations with age, sex, and smoking, with stronger links in systemic steroid users (HR: 3.54, 95% CI: 2.10-5.96, p < 0.001) and those with higher CCI (HR: 2.61, 95% CI: 1.64-4.12, p < 0.001). ICS may use increases AI risk in chronic airway disease patients, particularly among systemic steroid users and those with higher CCI. Close monitoring of high-risk patients is advised, and further research is needed to clarify mechanisms and optimize safe ICS use.

Association of moderate-to-vigorous physical activity with reduction of acute exacerbation in COPD patients using a dual ultra-long-acting bronchodilators

Inhaler therapy and physical activity (PA) are important methods of chronic obstructive pulmonary disease (COPD) management. This study aimed to investigate the additional benefit of moderate-to-vigorous PA (MVPA) in patients with COPD using a long-acting beta-agonists (LABA)/long-acting muscarinic antagonist (LAMA) combination. We emulated a target trial to estimate the benefit of MVPA in patients with COPD using a dual ultra-long-acting bronchodilators. We enrolled patients aged ≥ 40 who were diagnosed with COPD between 2014 and 2018, initiated a LABA/LAMA combination, and had not undergone regular MVPA. The main exposure was the initiation of MVPA, defined as vigorous aerobic exercise > 20 min per day on ≥ 3 days/week or moderate aerobic exercise > 30 min per day on ≥ 5 days/week. The main outcomes were the future usage of inhaled corticosteroids (ICS) and severe exacerbation. We identified 1,526 patients who initiated MVPA and 4,516 who did not. The median follow-up period was 3.0 years. The hazard ratio (HR) for future ICS usage in the MVPA initiation group was 0.83 (95% confidence intervals (CI): 0.72, 0.97) compared to the control group. The HR for severe exacerbation in the MVPA initiation group was 0.81 (95% CI: 0.68, 0.96) compared to the control group. Subgroup analyses by age, sex, body mass index, residence area, smoking and drinking status showed consistent benefits in these outcomes. Initiation of MVPA may offer an additional benefit for even COPD patients who use a dual ultra-long-acting bronchodilators.

Triple Therapy De-Escalation and Withdrawal of Inhaled Corticosteroids to Dual Bronchodilator Therapy in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Systematic Review and Meta-Analysis

Background/Objectives: The interpretation of evidence on the de-escalation of triple therapy with the withdrawal of inhaled corticosteroids (ICSs) to dual bronchodilator therapy with a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA) in patients with chronic obstructive pulmonary disease (COPD) is conflicting. We evaluated the efficacy and safety of ICS discontinuation from LABA-LAMA-ICS triple therapy compared to its continuation. Methods: We searched PubMed, Embase, Scopus, Web Of Science, clinicaltrial.gov, and CENTRAL for RCTs and observational studies from inception to 22 March 2024, investigating the effect of triple therapy de-escalation with the withdrawal of ICSs to dual therapy on the risk of COPD exacerbation, pneumonia, and lung function. This study was registered with PROSPERO, CRD42024527942. Results: A total of 3335 studies was screened; 3 RCTs and 3 real-world non-interventional studies were identified as eligible. The analysis of the time to the first moderate or severe exacerbation showed a pooled HR of 0.96 (95% CI, 0.80-1.15; I2 = 77%) for ICS withdrawal compared to triple therapy continuation. The analysis according eosinophil levels showed that COPD subjects with ≥300 eosinophils/µL had a significant increase in the incidence of moderate or severe exacerbations when de-escalated to LABA/LAMA (pooled HR: 1.35, 95% CI: 1.00-1.82; I2: 56%). ICS withdrawal did not significantly affect the risk of mortality and pneumonia. Conclusions: The de-escalation of triple therapy with ICS withdrawal does not affect the main outcomes evaluated (moderate or severe exacerbations, change in trough FEV1). COPD patients with high blood eosinophils (≥2% or ≥300 cells/µL) are most likely to benefit from continuing triple therapy.

Update on the pharmacological treatment of chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common syndrome associated with smoking and environmental exposures coupled with genetic susceptibility. Recent major advancements in the treatment of COPD patients have become available.

AREAS COVERED

New data on the role of classic bronchodilators, including short-acting and long-acting beta2-agonists and anti-muscarinic antagonists, in the treatment of COPD patients are discussed. Data promoting a more targeted approach to inhaled and systemic corticosteroid use in COPD are reviewed. Phosphodiesterase (PDE) inhibitors, including the recently approved PDE 3/4 inhibitor inhaled ensifentrine, are noted. Selective use of antibiotics can play a role in complex COPD patients. COPD patients with evidence of asthma-COPD overlap syndrome and type-two lymphocytic inflammatory-mediated airway constriction appear to respond to biologics, particularly the anti-IL-4/IL-3 antagonist monoclonal antibody, dupilumab.

EXPERT OPINION

New therapeutic options have made the approach and treatment of the COPD patient much more complicated. These options tend to be very expensive. Attention to identifying the endotype and phenotype will help direct the pharmacotherapy.

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

Background

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

Methods

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

Results

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

Conclusion

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

What every clinician should know about inflammation in COPD

Inflammation drives COPD pathogenesis and exacerbations. Although the conceptual framework and major players in the inflammatory milieu of COPD have been long established, the nuances of cellular interactions and the etiological differences that create heterogeneity in inflammatory profiles and treatment response continue to be revealed. This wealth of data and understanding is not only a boon to the researcher but also provides guidance to the clinician, moving the field closer to precision medicine. It is through this lens that this review seeks to describe the inflammatory processes at play in COPD, relating inflammation to pathological and functional changes, identifying patient-specific and disease-related factors that may influence clinical observations, and providing current insights on existing and emerging anti-inflammatory treatments and treatment targets, including biological therapies and phosphodiesterase (PDE) inhibitors.

The Current Molecular and Cellular Landscape of Chronic Obstructive Pulmonary Disease (COPD): A Review of Therapies and Efforts towards Personalized Treatment

Chronic obstructive pulmonary disease (COPD) ranks as the third leading cause of global illness and mortality. It is commonly triggered by exposure to respiratory irritants like cigarette smoke or biofuel pollutants. This multifaceted condition manifests through an array of symptoms and lung irregularities, characterized by chronic inflammation and reduced lung function. Present therapies primarily rely on maintenance medications to alleviate symptoms, but fall short in impeding disease advancement. COPD's diverse nature, influenced by various phenotypes, complicates diagnosis, necessitating precise molecular characterization. Omics-driven methodologies, including biomarker identification and therapeutic target exploration, offer a promising avenue for addressing COPD's complexity. This analysis underscores the critical necessity of improving molecular profiling to deepen our comprehension of COPD and identify potential therapeutic targets. Moreover, it advocates for tailoring treatment strategies to individual phenotypes. Through comprehensive exploration-based molecular characterization and the adoption of personalized methodologies, innovative treatments may emerge that are capable of altering the trajectory of COPD, instilling optimism for efficacious disease-modifying interventions.

Inflammation mechanism and research progress of COPD

Chronic obstructive pulmonary disease (COPD) is a common respiratory disease characterized by irreversible progressive airflow limitation, often manifested by persistent cough, sputum production and other respiratory symptoms that pose a serious threat to human health and affect the quality of life of patients. The disease is associated with chronic inflammation, which is associated with the onset and progression of COPD, but anti-inflammatory therapy is not first-line treatment. Inflammation has multiple manifestations and phenotypes, and this heterogeneity reveals different patterns of inflammation, making treatment difficult. This paper aims to explore the direction of more effective anti-inflammatory treatment by analyzing the nature of inflammation and the molecular mechanism of disease occurrence and development in COPD patients, and to provide new ideas for the treatment of COPD patients.

Differences in the Quantitative HRCT Characteristics of Patients with Asthma, COPD and Asthma-COPD Overlap and Their Relationships with Pulmonary Function

Purpose

We compared pulmonary function indices and quantitative CT parameters of airway remodeling, air trapping, and emphysema in asthmatic patients and patients with COPD and asthma-COPD overlap (ACO) and explored their relationships with airflow limitation.

Patients and Methods

Patients with asthma (n=48), COPD (n=52), and ACO (n=30) and controls (n=54) who completed pulmonary function tests and HRCT scans were retrospectively enrolled in our study. Quantitative CT analysis software was used to assess emphysema (LAA%), airway wall dimensions (wall area (WA), luminal area (LA), and wall area percentage (WA%)), and air trapping ((relative volume change of -860 HU to -950 HU (RVC-860 to-950) and the expiration-to-inspiration ratio of the mean lung density (MLDE/I))). Differences in pulmonary function and HRCT parameters were compared among the groups. Spearman correlation analysis and regression analysis were utilized to explore structure‒function relationships.

Results

The LAA% in COPD and ACO patients was significantly greater than that in asthmatic patients and controls. The WA% and WA in COPD and ACO patients were greater than those in controls, whereas the WA% and LA between asthmatic patients and controls reached statistical significance. The RVC-860 to -950 levels decreased in the following order: ACO, COPD, and asthma. RVC-860 to -950 independently predicted FEV1% in asthmatic patients; LAA% and MLDE/I in COPD patients; and LAA%, WA% and RVC-860 to -950 in ACO patients.

Conclusion

Comparable emphysema was observed in patients with COPD and ACO but not in asthmatic patients. All patients exhibited proximal airway remodeling. The bronchi were thickened outward in COPD and ACO patients but are thickened inward in asthmatic patients. Furthermore, air trapping in ACO patients was the most severe among all the groups. Indirect lung densitometry measurements might be more predictive of the degree of airflow limitation than direct airway measurements in obstructive airway diseases.

Poly(malic acid)-budesonide nanoconjugates embedded in microparticles for lung administration

To improve the therapeutic activity of inhaled glucocorticoids and reduce potential side effects, we designed a formulation combining the advantages of nanoparticles, which have an enhanced uptake by alveolar cells, allow targeted delivery and sustained drug release, as well as limited drug systemic passage, with those of microparticles, which display good alveolar deposition. Herein, a polymer-drug conjugate, poly(malic acid)-budesonide (PMAB), was first synthesized with either 11, 20, 33, or 43 mol% budesonide (drug:polymer from 1:8 to 3:4), the drug creating hydrophobic domains. The obtained conjugates self-assemble into nanoconjugates in water, yielding excellent drug loading of up to 73 wt%, with 80-100 nm diameters. In vitro assays showed that budesonide could be steadily released from the nanoconjugates, and the anti-inflammatory activity was preserved, as evidenced by reduced cytokine production in LPS-activated RAW 264.7 macrophages. Nanoconjugates were then embedded into microparticles through spray-drying with L-leucine, forming nano-embedded microparticles (NEMs). NEMs were produced with an aerodynamic diameter close to 1 µm and a density below 0.1 g.cm-3, indicative of a high alveolar deposition. NEMs spray-dried with the less hydrophobic nanoconjugates, PMAB 1:4, were readily dissolved in simulated lung fluid and were chosen for in vivo experiments to study pharmacokinetics in healthy rats. As it was released in vivo from NEMs, sustained distribution of budesonide was obtained for 48 h in lung tissue, cells, and lining fluid. With high loading rates, modulable release kinetics, and low cytotoxicity, these nanoconjugates delivered by NEMs are promising for the more efficient treatment of pulmonary inflammatory diseases.

Comparing Costs and Healthcare Resource Utilization (HCRU) Using LAMA versus LABA/ICS at Treatment Initiation for COPD: Findings from CITRUS (Comparing the Incidence of Tiotropium and ICS/LABA in Real-World Use in South Korea) Study

Background

COPD causes substantial economic burden on healthcare. Alternative treatment strategies for COPD can be associated with different costs dependent upon their relative safety and effectiveness. We compared costs and healthcare resource utilization (HCRU) associated with LAMA or LABA/ICS initiation.

Methods

Using the Korean National Health Insurance Service database, we enrolled COPD patients initiating treatment with LAMA or LABA/ICS between January 2005 and April 2015. Propensity score matched individuals were compared on all-cause and COPD-related medical costs and HCRU over a three-year follow-up period.

Results

A total of 2444 patients were enrolled in each treatment group. LAMA group was associated with significantly lower costs than LABA/ICS group, both in all-cause (403.08 vs 474.50 USD per patient per month [PPPM], cost ratio 1.18, 95% confidence interval [CI]=1.10-1.26, p<0.0001) and COPD-related (216.37 vs 267.32 USD PPPM, cost ratio 1.24, 95% CI=1.13-1.35, p<0.0001) medical costs. All-cause HCRU was not significantly different between groups, while COPD-related HRCU was higher in LAMA group (0.66 vs 0.60 medical visits PPPM, p<0.0001).

Conclusion

COPD patients initiating treatment with LAMA were associated with lower all-cause and COPD-related medical costs than those starting with LABA/ICS despite the similar all-cause HCRU and higher COPD-related HCRU. Initiation with LAMA is a cost-efficient option for the treatment of COPD.

Discovery and Optimization of Pyridazinones as PI3Kδ Selective Inhibitors for Administration by Inhalation

A hit-to-lead campaign pursuing the identification of novel inhalant small-molecule phosphatidylinositol 3-kinase (PI3K) inhibitors for the treatment of inflammatory respiratory diseases is disclosed. A synthetically versatile pyridazin-3(2H)-one scaffold was designed, and three exit vectors on the core moiety were used to explore chemical diversity and optimize pharmacological and absorption, distribution, metabolism, and excretion (ADME) properties. Desired modulation of PI3Kδ selectivity and cellular potency as well as ADME properties in view of administration by inhalation was achieved. Intratracheal administration of lead compound 26 resulted in a promising pharmacokinetic profile, thus demonstrating that the optimization strategy of in vitro profiles successfully translated to an in vivo setting.

Inhaled Corticosteroids May Not Affect the Clinical Outcomes of Pneumonia in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Although inhaled corticosteroids (ICS) is reportedly associated with a higher risk of pneumonia in chronic obstructive pulmonary disease (COPD), the clinical implications of ICS have not been sufficiently verified to determine their effect on the prognosis of pneumonia.

METHODS

The electronic health records of patients hospitalized for pneumonia with underlying COPD were retrospectively reviewed. Pneumonia was confirmed using chest radiography or computed tomography. The clinical outcomes of pneumonia in patients with COPD who received ICS and those who received long-acting bronchodilators other than ICS were compared.

RESULTS

Among the 255 hospitalized patients, 89 met the inclusion criteria. The numbers of ICS and non-ICS users were 46 and 43, respectively. The CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥65 years) scores at the initial presentation of pneumonia were comparable between the two groups. The proportions of patients with multilobar infiltration, pleural effusion, and complicated pneumonia in the radiological studies did not vary between the two groups. Additionally, the defervescence time, proportion of mechanical ventilation, intensive care unit admission, length of hospital stays, and mortality rate at 30 and 90 days were not significantly different between the two groups. ICS use and blood eosinophils count were not associated with all pneumonia outcomes and mortality in multivariate analyses.

CONCLUSION

The clinical outcomes of pneumonia following ICS use in patients with COPD did not differ from those in patients treated without ICS. Thus, ICS may not contribute to the severity and outcomes of pneumonia in patients with COPD.

Individualised treatment of COPD exacerbations using biomarkers

This review highlights key aspects of treating chronic obstructive pulmonary disease (COPD) exacerbation, focusing on the optimisation of systemic corticosteroid and antibiotic use through personalised treatment using biomarkers. Eosinophil-guided therapy reduces corticosteroid usage which might reduce side effects, while procalcitonin-guided therapy contributes to reduced antibiotic consumption. These approaches, documented through well-conducted randomized controlled trials, suggest the possibility of enhancing COPD exacerbation management, reducing potential side effects, and addressing concerns related to antibiotic resistance.

Chronic obstructive pulmonary disease and the airway microbiome: A review for clinicians

Chronic obstructive pulmonary disease (COPD) is a complex heterogeneous disease characterized by progressive airflow limitation and chronic inflammation. The progressive development and long-term repeated acute exacerbation of COPD make many patients still unable to control the deterioration of the disease after active treatment, and even eventually lead to death. An increasing number of studies have shown that the occurrence and development of COPD are closely related to the composition and changes of airway microbiome. This article reviews the interaction between COPD and airway microbiome, the potential mechanisms of interaction, and the treatment methods related to microbiome. We elaborated the internal correlation between airway microbiome and different stages of COPD, inflammatory endotypes, glucocorticoid and antibiotic treatment, analyze the pathophysiological mechanisms such as the "vicious cycle" hypothesis, abnormal inflammation-immune response of the host and the "natural selection" of COPD to airway microbiome, introduce the treatment of COPD related to microbiome and emphasize the predictive value of airway microbiome for the progression, exacerbation and prognosis of COPD, as well as the guiding role for clinical management of patients, in order to provide a new perspective for exploring the pathogenesis of COPD, and also provide clues and guidance for finding new treatment targets.

The application of nanoparticles as advanced drug delivery systems in Attenuating COPD

Chronic Obstructive Pulmonary Disease (COPD) is a dilapidating condition which is characterized by inflammation, an excess in free radical generation and airway obstruction. Currently, the drugs commercially available for the management of COPD pose several limitations such as systemic adverse effects, including bone density loss and an increased risk of developing pneumonia. Moreover, another limitation includes the need for regular and frequent dosing regimens; which can affect the adherence to the therapy. Furthermore, these current treatments provide symptomatic relief; however, they cannot stop the progression of COPD. Comparatively, nanoparticles (NPs) provide great therapeutic potential to treat COPD due to their high specificity, biocompatibility, and higher bioavailability. Furthermore, the NP-based drug delivery systems involve less frequent dosing requirements and in smaller doses which assist in minimizing side effects. In this review, the benefits and limitations of conventional therapies are explored, while providing an in-depth insight on advanced applications of NP-based systems in the treatment of COPD.

Which patients with COPD need an inhaled corticosteroid?

ABSTRACT

Inhaled bronchodilators are recommended to treat patients with any category of chronic obstructive pulmonary disease (COPD). Clinical practice guidelines conditionally recommend inhaled corticosteroids (ICS) for patients with eosinophilic COPD phenotypes, patients who experience hospitalizations for or frequent severe exacerbations of COPD, and patients with comorbid asthma. This article outlines which patients with COPD may benefit from an ICS.

Risk of Pneumonia in Patients with COPD Initiating Fixed Dose Inhaled Corticosteroid (ICS) / Long-Acting Bronchodilator (LABD) Formulations Containing Extrafine Beclometasone Dipropionate versus Patients Initiating LABD Without ICS

Background

Combined ICS and long-acting bronchodilators (LABD) more effectively reduce COPD exacerbations than LABD therapy alone. Corticosteroid-related adverse effects, including pneumonia, limit ICS use. Previous data suggest this risk is lower for extrafine beclometasone (ef-BDP). We compared pneumonia risk among new users of fixed dose ICS/LABD formulations containing ef-BDP, versus patients initiating LABD without any ICS.

Methods

A propensity-matched historical cohort study design used data from OPCRD. COPD patients with ≥1 year of continuous data who initiated LABD or ICS/LABD formulations containing ef-BDP were matched. Primary outcome was time to pneumonia event, as treated, using either sensitive (physician diagnosed) or specific (physician diagnosed and x-ray or hospital admission confirmed) definitions, with non-inferiority boundary of 15%.

Results

23,898 COPD patients were matched, who were 68±11 years, 54.3% male and 56% current-smokers, while 43% were former-smokers. Initiation of ef-BDP/LABD was not associated with an increased risk of pneumonia versus LABD, for either a sensitive 0.89 (0.78-1.02), P = 0.08 or a specific 0.91 (0.78-1.05), P = 0.18 definition of pneumonia. The probability of remaining pneumonia free 1-year after ef-BDP/LABD was 98.4%, which was comparable to LABD at 97.7%, and was sustained up to 6 years of observation; non-inferiority criterion was met for both definitions. Initiation of ef-BDP/LABD was also associated with a reduced risk of developing LRTIs in the propensity matched cohort.

Conclusion

Risk of pneumonia when using ICS for the management of COPD reported in several randomised controlled trials may not be relevant with ef-BDP in a diverse real-world clinical population.

Hospitalized acute exacerbation in chronic obstructive pulmonary disease - impact on long-term renal outcomes

INTRODUCTION

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common and preventable event in patients with chronic obstructive pulmonary disease (COPD). Data regarding the impact of AECOPD on short- and long-term renal outcomes are lacking.

METHODS

We included all COPD patients who were followed at Queen Mary Hospital (QMH) in year 2015 and reviewed their clinical/renal outcomes in subsequent five years. Relationships between AECOPD and adverse renal outcomes were evaluated.

RESULTS

371 COPD patients were included. 169 patients had hospitalized AECOPD in past one year (HAE group) while 202 patients did not (non-HAE group). 285 patients (76.8%) had renal progression/death and 102 (27.5%) patients developed acute kidney injury (AKI). HAE group showed a more rapid eGFR decline than non-HAE group (-4.64 mL/min/1.73m2/year vs. -2.40 mL/min/1.73m2/year, p = 0.025). HAE group had significantly higher risk for renal progression/death at 5 years [adjusted OR (aOR) 2.380 (95% CI = 1.144-4.954), p = 0.020]. The frequency of hospitalized AECOPD in past 3 years, any AECOPD in past 3 years, hospitalized AECOPD in past 3 years were also predictive of renal progression/death at 5 years [aOR were 1.176 (95% CI = 1.038- 1.331), 2.998 (95% CI = 1.438-6.250) and 2.887 (95% CI = 1.409-5.917) respectively; p = 0.011, 0.003 and 0.004]. HAE group also showed significantly higher risk of AKI [adjusted HR (aHR) 2.430; 95% CI = 1.306-4.519, p = 0.005].

CONCLUSIONS

AECOPD, in particular HAE, was associated with increased risk of renal progression/death and AKI. Prevention of AECOPD, especially HAE, may potentially improve short- and long-term renal outcomes in COPD patients.

Adjustments to maintenance therapy and the reasoning behind them among COPD outpatients in Austria: the STEP study

Background

Adjustments to COPD maintenance treatment are based on different guidelines. In Austria, there is a lack of real-world data on treatment adjustments of COPD outpatients and their underlying rationale. The STEP study characterised change patterns of pharmacological maintenance therapy in COPD outpatients in predefined categories of step-up, step-down and switch, the underlying reasons, and predictors in clinical routine in Austria.

Methods

STEP was a single-visit non-interventional study in Austria. 77 pulmonologists based in outpatient clinics documented previous and adapted COPD therapy, reason for change, patient characteristics, COPD phenotype, and lung function. Patients' COPD symptom burden was assessed by using the COPD Assessment Test (CAT). Predictors for therapy changes were identified.

Results

1137 patients were studied (mean±sd age 67±10 years; 56.9% male; mean forced expiratory volume in 1 s 56.3% predicted; Global Initiative for Chronic Obstructive Lung Disease B and E stages 66% and 19%, respectively; mean CAT score 17.5). Therapy step-up was observed in 59.3%, treatment switch in 21.7% and step-down in 19.0% of patients. Triple therapy comprised the biggest proportion of inhalation treatment (53.3%). Physicians reported lung function, symptom burden and exacerbations as the main reasons for step-up or step-down, whereas switches within the same treatment class were predominantly caused by device issues. Predictors for step-up were comorbid asthma and exacerbations among others.

Conclusions

STEP was the first study to investigate COPD therapy changes in clinical routine in Austria. The most frequent treatment adjustment was step-up, followed by treatment switch and step-down. Symptom burden, stable or improved lung function and inhalation device handling were the most frequently given reasons for adjustments.

Cytotoxic CD4+ tissue-resident memory T cells are associated with asthma severity

BACKGROUND

Patients with severe uncontrolled asthma represent a distinct endotype with persistent airway inflammation and remodeling that is refractory to corticosteroid treatment. CD4+ TH2 cells play a central role in orchestrating asthma pathogenesis, and biologic therapies targeting their cytokine pathways have had promising outcomes. However, not all patients respond well to such treatment, and their effects are not always durable nor reverse airway remodeling. This observation raises the possibility that other CD4+ T cell subsets and their effector molecules may drive airway inflammation and remodeling.

METHODS

We performed single-cell transcriptome analysis of >50,000 airway CD4+ T cells isolated from bronchoalveolar lavage samples from 30 patients with mild and severe asthma.

FINDINGS

We observed striking heterogeneity in the nature of CD4+ T cells present in asthmatics' airways, with tissue-resident memory T (TRM) cells making a dominant contribution. Notably, in severe asthmatics, a subset of CD4+ TRM cells (CD103-expressing) was significantly increased, comprising nearly 65% of all CD4+ T cells in the airways of male patients with severe asthma when compared to mild asthma (13%). This subset was enriched for transcripts linked to T cell receptor activation (HLA-DRB1, HLA-DPA1) and cytotoxicity (GZMB, GZMA) and, following stimulation, expressed high levels of transcripts encoding for pro-inflammatory non-TH2 cytokines (CCL3, CCL4, CCL5, TNF, LIGHT) that could fuel persistent airway inflammation and remodeling.

CONCLUSIONS

Our findings indicate the need to look beyond the traditional T2 model of severe asthma to better understand the heterogeneity of this disease.

FUNDING

This research was funded by the NIH.

The treatable traits approach to adults with obstructive airways disease in primary and secondary care

The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.

The dual-targeting mechanism of an anti-inflammatory diarylheptanoid from Curcuma zedoaria (Christm.) Roscoe with the capacity for β2-adrenoreceptor agonism and NLRP3 inhibition

Chronic obstructive pulmonary disease (COPD) is a common respiratory disease characterized by symptoms of shortness of breath and chronic inflammation. Curcuma zedoaria (Christm.) Roscoe is a well-documented traditional medical herb that is frequently used in the treatment of COPD. Previously, we identified a diarylheptanoid compound (1-(4-hydroxy-5-methoxyphenyl)-7-(4,5-dihydroxyphenyl)-3,5-dihydroxyheptane; abbreviated as HMDD) from this herb that exhibited potent agonistic activity on β2-adrenergic receptors (β2 adrenoreceptor) that are present on airway smooth muscle cells. In this work, we used chemically synthesized HMDD compound, and confirmed its bioactivity on β2 adrenoreceptors. Then by a proteomics study and anti-inflammatory evaluation detections, we found that HMDD downregulated the nucleotide-binding oligomerization domain (NOD)-like receptor (NLR) signaling pathway and suppressed the NLRP3 receptor expression in RAW264.7 macrophages and in a COPD model in A549 lung carcinoma cells. HMDD also decreased nitric oxide production levels, and impacted other interleukins and the phosphorylation of NF-κB and ERK pathways. We performed molecular docking of HMDD on β2 adrenoreceptor and NLRP3 protein models. This work reports the anti-inflammatory effects of HMDD and suggests a dual-targeting mechanism of β2-adrenoreceptor agonism and NLRP3 inhibition. Such a mechanism scientifically supports the clinical uses of Curcuma zedoaria (Christm.) Roscoe in treating COPD, as it can simultaneously relieve persistent breathlessness and inflammation. HMDD can be considered as a potential non-steroidal anti-inflammatory drug in novel therapy design for the treatment of COPD and other inflammatory diseases.

Optimizing inhaled corticosteroid use in patients with chronic obstructive pulmonary disease: assessing blood eosinophils, neutrophil-to-lymphocyte ratio, and mortality outcomes in US adults

Objective

Accurate biomarkers for evaluating mortality rates in patients with chronic obstructive pulmonary disease (COPD) remain scarce. This study aimed to explore the relationships between mortality rates in patients with COPD and blood eosinophil counts, neutrophil counts, and lymphocyte counts, along with the neutrophil-to-lymphocyte ratio (NLR). Additionally, we sought to identify the optimal response values for these biomarkers when utilizing inhaled corticosteroids (ICS).

Methods

Utilizing a nationally representative, multistage cross-sectional design and mortality correlation study, we analyzed data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 involving US adults aged 40 years or older with COPD. The primary endpoint was all-cause mortality, with Kaplan-Meier survival curves and restricted cubic splines applied to illustrate the relationship between leukocyte-based inflammatory markers and mortality. The analysis was conducted in 2023.

Results

Our analysis included 1,715 COPD participants, representing 6,976,232 non-institutionalized US residents [weighted mean age (SE), 62.09 (0.28) years; range, 40-85 years]. Among the participants, men constituted 50.8% of the population, and the weighted mean follow-up duration was 84.9 months. In the ICS use group, the weighted proportion of participants over 70 years old was significantly higher compared with the non-ICS use group (31.39% vs 25.52%, p < 0.0001). The adjusted hazard ratios for all-cause mortality related to neutrophil counts, lymphocyte counts, and NLR were 1.10 [95% confidence interval (CI), 1.04-1.16, p < 0.001], 0.83 (95% CI, 0.71-0.98; p = 0.03), and 1.10 (95% CI, 1.05-1.15; p < 0.0001), respectively. Optimal ICS response was linked with higher levels of eosinophil count (≥240 cells/μL), neutrophil count (≥3,800 cells/μL), NLR (≥4.79), and lower levels of lymphocyte count (<2,400 cells/μL).

Conclusion

Adjusted baseline neutrophil, lymphocyte counts, and NLR serve as independent risk factors for all-cause mortality in patients with COPD. Further, ICS application appears to mitigate mortality risk, particularly when NLR levels reach 4.79 or higher, underlining the importance of ICS in COPD management.

The effect of inhaled extrafine beclometasone dipropionate/formoterol fumarate/glycopyrronium bromide on distal and central airway indices, assessed using Functional Respiratory Imaging in COPD (DARWiIN)

BACKGROUND

This study, in patients with symptomatic chronic obstructive pulmonary disease (COPD), explored switching therapy from non-extrafine high-dose inhaled corticosteroid/long-acting β2-agonist (ICS/LABA; fluticasone propionate/salmeterol [FP/SLM]) to extrafine medium-dose beclometasone dipropionate/formoterol fumarate dihydrate/glycopyrronium (BDP/FF/G), both via dry-powder inhaler. Functional Respiratory Imaging, a quantitative computed tomography method with 3D reconstructions of pulmonary anatomy, was used to assess airway geometry and lung function.

METHODS

Patients receiving a stable ICS/LABA regimen for ≥ 8 weeks were switched to FP/SLM 500/50 µg, one inhalation twice-daily (high-dose ICS) for 6 weeks. After baseline assessments (Visit 2 [V2]), therapy was switched to BDP/FF/G 100/6/10 µg, two inhalations twice-daily (medium-dose ICS) for 6 weeks, followed by V3. The primary endpoints were percentage changes in specific image-based airway volume (siVaw) and resistance (siRaw) from baseline to predose at V3 (i.e., chronic effects), assessed at total lung capacity (TLC) in central and distal lung regions. Secondary endpoints included siVaw and siRaw changes from pre-dose to post-dose at V2, and from pre-dose to post-dose at V3 at TLC (i.e., acute effects), and chronic and acute changes in siVaw and siRaw at functional residual capacity (FRC). Pre-dose forced expiratory volume in 1 s (FEV1) and COPD Assessment Test (CAT) were also assessed.

RESULTS

There were no significant changes in pre-dose siVaw or siRaw at TLC from baseline to V3, although at FRC there was a significant decrease in mean siRaw in the distal airways (- 63.6%; p = 0.0261). In addition, in the distal airways there were significant acute effects at TLC on mean siVaw and siRaw (siVaw: 39.8% and 62.6%; siRaw: - 51.1% and - 57.2%, V2 and V3, respectively; all p < 0.001) and at FRC at V2 (siVaw: 77.9%; siRaw: - 67.0%; both p < 0.001). At V3, the mean change in pre-dose FEV1 was 62.2 mL (p = 0.0690), and in CAT total score was - 3.30 (p < 0.0001).

CONCLUSIONS

In patients with symptomatic COPD receiving high-dose ICS/LABA, adding a long-acting muscarinic antagonist while decreasing the ICS dose by switching to medium-dose extrafine BDP/FF/G was associated with improved airway indices, especially in the distal airways, together with improvements in respiratory health status. Trial registration ClinicalTrials.gov (NCT04876677), first posted 6th May 2021.

Scutellarein alleviates chronic obstructive pulmonary disease through inhibition of ferroptosis by chelating iron and interacting with arachidonate 15-lipoxygenase

Ferroptosis, an iron-dependent cell death characterized by lethal lipid peroxidation, is involved in chronic obstructive pulmonary disease (COPD) pathogenesis. Therefore, ferroptosis inhibition represents an attractive strategy for COPD therapy. Herein, we identified natural flavonoid scutellarein as a potent ferroptosis inhibitor for the first time, and characterized its underlying mechanisms for inhibition of ferroptosis and COPD. In vitro, the anti-ferroptotic activity of scutellarein was investigated through CCK8, real-time quantitative polymerase chain reaction (RT-qPCR), Western blotting, flow cytometry, and transmission electron microscope (TEM). In vivo, COPD was induced by lipopolysaccharide (LPS)/cigarette smoke (CS) and assessed by changes in histopathological, inflammatory, and ferroptotic markers. The mechanisms were investigated by RNA-sequencing (RNA-seq), electrospray ionization mass spectra (ESI-MS), local surface plasmon resonance (LSPR), drug affinity responsive target stability (DARTS), cellular thermal shift assay (CETSA), and molecular dynamics. Our results showed that scutellarein significantly inhibited Ras-selective lethal small molecule (RSL)-3-induced ferroptosis and mitochondria injury in BEAS-2B cells, and ameliorated LPS/CS-induced COPD in mice. Furthermore, scutellarein also repressed RSL-3- or LPS/CS-induced lipid peroxidation, GPX4 down-regulation, and overactivation of Nrf2/HO-1 and JNK/p38 pathways. Mechanistically, scutellarein inhibited RSL-3- or LPS/CS-induced Fe2+ elevation through directly chelating Fe2+ . Moreover, scutellarein bound to the lipid peroxidizing enzyme arachidonate 15-lipoxygenase (ALOX15), which resulted in an unstable state of the catalysis-related Fe2+ chelating cluster. Additionally, ALOX15 overexpression partially abolished scutellarein-mediated anti-ferroptotic activity. Our findings revealed that scutellarein alleviated COPD by inhibiting ferroptosis via directly chelating Fe2+ and interacting with ALOX15, and also highlighted scutellarein as a candidate for the treatment of COPD and other ferroptosis-related diseases.

Mechanism of KLF9 in airway inflammation in chronic obstructive pulmonary

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an airway-associated lung disorder, resulting in airway inflammation. This article aimed to explore the role of the krüppel-like factor 9 (KLF9)/microRNA (miR)-494-3p/phosphatase and tensin homolog (PTEN) axis in airway inflammation and pave a theoretical foundation for the treatment of COPD.

METHODS

The COPD mouse model was established by exposure to cigarette smoke, followed by measurements of total cells, neutrophils, macrophages, and hematoxylin and eosin staining. The COPD cell model was established on human lung epithelial cells BEAS-2B using cigarette smoke extract. Cell viability was assessed by cell counting kit-8 assay. miR-494-3p, KLF9, PTEN, and NLR family, pyrin domain containing 3 (NLRP3) levels in tissues and cells were measured by quantitative real-time polymerase chain reaction or Western blot assay. Inflammatory factors (TNF-α/IL-6/IL-8/IFN-γ) were measured by enzyme-linked immunosorbent assay. Interactions among KLF9, miR-494-3p, and PTEN 3'UTR were verified by chromatin immunoprecipitation and dual-luciferase assays.

RESULTS

KLF9 was upregulated in lung tissues of COPD mice. Inhibition of KLF9 alleviated airway inflammation, reduced intrapulmonary inflammatory cell infiltration, and repressed NLRP3 expression. KLF9 bound to the miR-494-3p promoter and increased miR-494-3p expression, and miR-494-3p negatively regulated PTEN expression. miR-494-3p overexpression or Nigericin treatment reversed KLF9 knockdown-driven repression of NLRP3 inflammasome and inflammation.

CONCLUSION

KLF9 bound to the miR-494-3p promoter and repressed PTEN expression, thereby facilitating NLRP3 inflammasome-mediated inflammation.

Association between inhaled corticosteroid use and risk of hyperglycemia in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

Objectives

Chronic obstructive pulmonary disease (COPD) patients have a higher risk of developing diabetes, and studies suggest that inhaled corticosteroids (ICSs) use may be associated with a higher risk of diabetes, particularly at higher doses. This study aims to investigate the effects of ICS use on the risk of diabetes and blood glucose levels in COPD patients.

Materials and Methods

A systematic search was carried out on the PubMed, EBSCOhost, and ProQuest databases using the terms "Inhaled Corticosteroids," "Diabetes," and "Chronic Obstructive Pulmonary Disease" for the period between 2013 and 2023. The systematic review adhered to the PRISMA 2020 guideline. A meta-analysis was conducted using a random-effects model using the RevMan 5 software.

Results

A total of 14 studies were included in the final analysis, with 10 randomized controlled trials (RCTs) and 4 observational studies. Two observational studies investigated the relationship between ICS dose and diabetes risk. A meta-analysis of the RCTs studies showed a nonstatistically significant tendency toward increased blood glucose (odds ratio [OR] 1.07 and 95% confidence interval [CI] 0.88-1.30) after a 52-week follow-up. Whereas the observational studies showed a tendency toward an increased risk of diabetes (OR 1.40 and 95% CI 0.96-2.03). Furthermore, a subgroup meta-analysis of high-dose ICS (>900 μg/day) showed a significant increase in the risk of diabetes (OR 1.20 and 95% CI 1.09-1.32).

Conclusion

Short-term use of ICS does not have a significant effect on blood glucose. However, long-term use, especially at higher doses, can increase the risk of developing diabetes.

COPD treatment - a conceptual review based on critical endpoints

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is one of the main causes of death and disability worldwide. Many treatment options are now available, but criteria for choosing inhaled bronchodilators and inhaled corticosteroids have been under discussion. New trials have highlighted the role of patient`s characteristics, such as eosinophil count and exacerbation history, in selecting the most effective personalised treatment option.

METHODS

In this conceptual review, an in-depth rationale is developed with an integrative approach to COPD treatment, gathering data from the main clinical trials performed so far and that may provide support for actual GOLD 2023 recommendations.

RESULTS

According to the patient's characteristics and profile, different treatment options, including mono, dual and triple therapies, are presented in a diagram matrix, comparing their efficacy in terms of reduction of exacerbations and mortality risk.

DISCUSSION AND CONCLUSION

Eosinophil counts and past exacerbation profile may play equally relevant roles to predict the individual risk and the potential response to inhaled corticosteroids. Thus, a comprehensive approach considering these two predictors is needed to aid clinicians decide preventative actions and choice of a first-line or step-up treatment.

Advancing Treatment Strategies: A Comprehensive Review of Drug Delivery Innovations for Chronic Inflammatory Respiratory Diseases

Chronic inflammatory respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis, present ongoing challenges in terms of effective treatment and management. These diseases are characterized by persistent inflammation in the airways, leading to structural changes and compromised lung function. There are several treatments available for them, such as bronchodilators, immunomodulators, and oxygen therapy. However, there are still some shortcomings in the effectiveness and side effects of drugs. To achieve optimal therapeutic outcomes while minimizing systemic side effects, targeted therapies and precise drug delivery systems are crucial to the management of these diseases. This comprehensive review focuses on the role of drug delivery systems in chronic inflammatory respiratory diseases, particularly nanoparticle-based drug delivery systems, inhaled corticosteroids (ICSs), novel biologicals, gene therapy, and personalized medicine. By examining the latest advancements and strategies in these areas, we aim to provide a thorough understanding of the current landscape and future prospects for improving treatment outcomes in these challenging conditions.

Rational use of inhaled corticosteroids for the treatment of COPD

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.

Airway smooth muscle area to predict steroid responsiveness in COPD patients receiving triple therapy (HISTORIC): a randomised, placebo-controlled, double-blind, investigator-initiated trial

BACKGROUND

Although inhaled corticosteroids (ICS) are highly effective in asthma, they provide significant, but modest, clinical benefit in COPD. Here, we tested the hypothesis that high bronchial airway smooth muscle cell (ASMC) area in COPD is associated with ICS responsiveness.

METHODS

In this investigator-initiated and -driven, double-blind, randomised, placebo-controlled trial (HISTORIC), 190 COPD patients, Global Initiative for Chronic Obstructive Lung Disease stage B-D, underwent bronchoscopy with endobronchial biopsy. Patients were divided into groups A and B, with high ASMC area (HASMC: >20% of the bronchial tissue area) and low ASMC area (LASMC: ≤20% of the bronchial tissue area), respectively, and followed a run-in period of 6 weeks on open-label triple inhaled therapy with aclidinium (ACL)/formoterol (FOR)/budesonide (BUD) (400/12/400 μg twice daily). Subsequently, patients were randomised to receive either ACL/FOR/BUD or ACL/FOR/placebo and followed for 12 months. The primary end-point of the study was the difference in post-bronchodilator forced expiratory volume in 1 s (FEV1) over 12 months between patients with LASMC and HASMC receiving or not receiving ICS.

RESULTS

In patients with LASMC, ACL/FOR/BUD did not significantly improve FEV1 over 12 months, as compared to ACL/FOR/placebo (p=0.675). However, in patients with HASMC, ACL/FOR/BUD significantly improved FEV1, as compared to ACL/FOR/placebo (p=0.020). Over 12 months, the difference of FEV1 change between the ACL/FOR/BUD group and the ACL/FOR/placebo group was 50.6 mL·year-1 within the group of patients with LASMC and 183.0 mL·year-1 within the group of patients with HASMC.

CONCLUSION

COPD patients with ΗASMC respond better to ICS than patients with LASMC, suggesting that this type of histological analysis may predict ICS responsiveness in COPD patients receiving triple therapy.

Management of eosinophil-associated inflammatory diseases: the importance of a multidisciplinary approach

Elevated eosinophil counts in blood and tissue are a feature of many pathological processes. Eosinophils can migrate and accumulate in a wide variety of tissues and, by infiltrating a target organ, can mediate the development of several inflammatory diseases. The normalization of eosinophilia is a common biomarker of a treatable trait and can also be used as a prognostic and predictive biomarker since it implies a reduction in type 2 inflammation that contributes to disease pathogenesis. Biological therapies targeting this cell type and its proinflammatory mediators have been shown to be effective in the management of a number of eosinophilic diseases, and for this reason they constitute a potential common strategy in the treatment of patients with various multimorbidities that present with type 2 inflammation. Various biological options are available that could be used to simultaneously treat multiple target organs with a single drug, bearing in mind the need to offer personalized treatments under the umbrella of precision medicine in all patients with eosinophil-associated diseases (EADs). In addition to reviewing these issues, we also discuss a series of perspectives addressing the management of EAD patients from a multidisciplinary approach, with the collaboration of health professionals from different specialties who manage the different multimorbidities that frequently occur in these patients. We examine the basic principles of care that this multidisciplinary approach must cover and present a multidisciplinary expert opinion regarding the ideal management of patients with EADs, from diagnosis to therapeutic approach and follow-up.

Budesonide/formoterol maintenance and reliever therapy versus fluticasone/salmeterol fixed-dose treatment in patients with COPD

BACKGROUND

Maintenance and reliever therapy (MART) with inhaled corticosteroid (ICS)/formoterol effectively reduces exacerbations in asthma. We aimed to investigate its efficacy compared with fixed-dose fluticasone/salmeterol in chronic obstructive pulmonary disease (COPD).

METHODS

Patients with COPD and ≥1 exacerbation in the previous 2 years were randomly assigned to open-label MART (Spiromax budesonide/formoterol 160/4.5 µg 2 inhalations twice daily+1 prn) or fixed-dose therapy (Diskus fluticasone propionate/salmeterol combination (FSC) 500/50 µg 1 inhalation twice daily+salbutamol 100 µg prn) for 1 year. The primary outcome was rate of moderate/severe exacerbations, defined by treatment with oral prednisolone and/or antibiotics.

RESULTS

In total, 195 patients were randomised (MART Bud/Form n=103; fixed-dose FSC n=92). No significant difference was seen between MART and FSC therapy in exacerbation rates (1.32 vs 1.32 /year, respectively, rate ratio 1.05 (95% CI 0.79 to 1.39); p=0.741). No differences in lung function parameters or health status were observed. Total ICS dose was significantly lower with MART than FSC therapy (budesonide-equivalent 928 µg/day vs 1747 µg/day, respectively, p<0.05). Similar proportions of patients reported adverse events (MART Bud/Form: 73% vs fixed-dose FSC: 68%, p=0.408) and pneumonias (MART: 5% vs FSC: 1%, p=0.216).

CONCLUSIONS

This first study of MART in COPD found that budesonide/formoterol MART might be similarly effective to fluticasone/salmeterol fixed-dose therapy in moderate to severe patients with COPD, at a lower daily ICS dosage. Further evidence is needed about long-term safety.

Empyema Caused by Pasteurella multocida in a Patient With Chronic Obstructive Respiratory Disease Taking Inhaled Corticosteroids: A Case Report

Pasteurella multocida (P. multocida) infection develops in patients with chronic obstructive pulmonary disease (COPD). Inhaled corticosteroids (ICS) are used for the treatment of COPD. Herein, we report a case of empyema caused by P. multocida in a patient using ICS for COPD. A 79-year-old man with COPD presented with general fatigue. He was treated with triple therapy including ICS. Contrast-enhanced computed tomography revealed encapsulated pleural effusion in the left chest. We initiated antibiotics, sulbactam sodium/ampicillin sodium (3 g × 4), and thoracic drainage. His pleural effusion culture turned out positive and P. multocida was detected. The patient was diagnosed with empyema caused by P. multocida. The triple therapy combination, including ICS, was changed to a double therapy combination without ICS. The subsequent progress was relatively good, and on the 49th day of hospitalization, the patient was discharged. The onset of P. multocida infection may be associated with ICS use, which may best be avoided in a patient with COPD who is at risk of P. multocida infection.

Combination therapy with long-acting bronchodilators and the risk of major adverse cardiovascular events in patients with COPD: a systematic review and meta-analysis

INTRODUCTION

Accumulated high-quality data from randomised controlled trials (RCTs) indicate that long-acting muscarinic antagonist (LAMA)/long-acting β2 agonist (LABA) combination therapy significantly improves clinical symptoms and health status in patients with chronic obstructive pulmonary disease (COPD) and reduces exacerbation risk. However, there is a growing concern that LAMA/LABA therapy may increase the risk of cardiovascular disease in patients with COPD. The aim of this paper is to determine whether the use of LAMA/LABA combination therapy modifies the risk of cardiovascular disease in patients with COPD.

METHODS

Two reviewers independently searched Embase, PubMed and Cochrane Library to identify relevant RCTs of LAMA/LABA or LABA/LAMA/inhaled corticosteroids (ICS) for the management of patients with COPD that reported on cardiovascular end-points. The primary outcome was major adverse cardiovascular events (MACE), which was a composite of cardiovascular death, myocardial infarction or stroke.

RESULTS

A total of 51 RCTs enrolling 91 021 subjects were analysed. Both dual LAMA/LABA (1.6% versus 1.3%; relative risk 1.42, 95% CI 1.11-1.81) and triple therapy (1.6% versus 1.4%; relative risk 1.29, 95% CI 1.03-1.61) significantly increased the risk of MACE compared with ICS/LABA. The excess risk was most evident in RCTs in which the average underlying baseline risk for MACE was >1% per year. Compared with LAMA only, LABA only or placebo, dual LAMA/LABA therapy did not significantly increase the risk of MACE, though these comparisons may have lacked sufficient statistical power.

CONCLUSION

Compared with ICS/LABA, dual LAMA/LABA or triple therapy increases cardiovascular risk in patients with COPD. This should be considered in the context of the incremental benefits of these therapies for symptoms and exacerbation rates in patients with COPD, especially in those with a MACE risk of >1% per year.