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Wu Z, Smith DJF, Yazbeck L, Saunders P, Smith JA, Maher TM, Molyneaux PL. Cough Severity Visual Analog Scale Assesses Cough Burden and Predicts Survival in Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2024; 209:1165-1167. [PMID: 38301238 DOI: 10.1164/rccm.202311-2169le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/01/2024] [Indexed: 02/03/2024] Open
Affiliation(s)
- Zhe Wu
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - David J F Smith
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Leda Yazbeck
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Peter Saunders
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Jaclyn A Smith
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom; and
| | - Toby M Maher
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Hastings Centre for Pulmonary Research and Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
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Wu Z, Spencer LG, Banya W, Westoby J, Tudor VA, Rivera-Ortega P, Chaudhuri N, Jakupovic I, Patel B, Thillai M, West A, Wijsenbeek M, Maher TM, Smith JA, Molyneaux PL. Morphine for treatment of cough in idiopathic pulmonary fibrosis (PACIFY COUGH): a prospective, multicentre, randomised, double-blind, placebo-controlled, two-way crossover trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:273-280. [PMID: 38237620 DOI: 10.1016/s2213-2600(23)00432-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/25/2023] [Accepted: 11/09/2023] [Indexed: 04/02/2024]
Abstract
BACKGROUND Idiopathic pulmonary fibrosis is a progressive fibrotic lung disease, with most patients reporting cough. Currently, there are no proven treatments. We examined the use of low dose controlled-release morphine compared with placebo as an antitussive therapy in individuals with idiopathic pulmonary fibrosis. METHODS The PACIFY COUGH study is a phase 2, multicentre, randomised, double-blind, placebo-controlled, two-way crossover trial done in three specialist centres in the UK. Eligible patients aged 40-90 years had a diagnosis of idiopathic pulmonary fibrosis within 5 years, self-reported cough (lasting >8 weeks), and a cough visual analogue scale (VAS) score of 30 mm or higher. Patients were randomly assigned (1:1) to placebo twice daily or controlled-release morphine 5 mg orally twice daily for 14 days followed by crossover after a 7-day washout period. Patients were randomised sequentially to a sequence group defining the order in which morphine and placebo were to be given, according to a computer-generated schedule. Patients, investigators, study nurses, and pharmacy personnel were masked to treatment allocation. The primary endpoint was percentage change in objective awake cough frequency (coughs per h) from baseline as assessed by objective digital cough monitoring at day 14 of treatment in the intention-to-treat population, which included all randomised participants. Safety data were summarised for all patients who took at least one study drug and did not withdraw consent. This study was registered at ClinicalTrials.gov, NCT04429516, and has been completed. FINDINGS Between Dec 17, 2020, and March 21, 2023, 47 participants were assessed for eligibility and 44 were enrolled and randomly allocated to treatment. Mean age was 71 (SD 7·4) years, and 31 (70%) of 44 participants were male and 13 (30%) were female. Lung function was moderately impaired; mean forced vital capacity (FVC) was 2·7 L (SD 0·76), mean predicted FVC was 82% (17·3), and mean predicted diffusion capacity of carbon monoxide was 48% (10·9). Of the 44 patients who were randomised, 43 completed morphine treatment and 41 completed placebo treatment. In the intention-to-treat analysis, morphine reduced objective awake cough frequency by 39·4% (95% CI -54·4 to -19·4; p=0·0005) compared with placebo. Mean daytime cough frequency reduced from 21·6 (SE 1·2) coughs per h at baseline to 12·8 (1·2) coughs per h with morphine, whereas cough rates did not change with placebo (21·5 [SE 1·2] coughs per h to 20·6 [1·2] coughs per h). Overall treatment adherence was 98% in the morphine group and 98% in the placebo group. Adverse events were observed in 17 (40%) of 43 participants in the morphine group and six (14%) of 42 patients in the placebo group. The main side-effects of morphine were nausea (six [14%] of 43 participants) and constipation (nine [21%] of 43). One serious adverse event (death) occurred in the placebo group. INTERPRETATION In patients with cough related to idiopathic pulmonary fibrosis, low dose controlled-release morphine significantly reduced objective cough counts over 14 days compared with placebo. Morphine shows promise as an effective treatment to palliate cough in patients with idiopathic pulmonary fibrosis, and longer term studies should be the focus of future research. FUNDING The Jon Moulton Charity Trust.
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Affiliation(s)
- Zhe Wu
- National Heart and Lung Institute, Imperial College, London, UK; Royal Brompton and Harefield Hospitals, London, UK
| | - Lisa G Spencer
- Liverpool Interstitial Lung Disease Service, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - John Westoby
- Royal Brompton and Harefield Hospitals, London, UK
| | | | - Pilar Rivera-Ortega
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK
| | | | | | - Brijesh Patel
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK
| | - Muhunthan Thillai
- Royal Papworth Hospital, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Alex West
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marlies Wijsenbeek
- Centre for Interstitial Lung Disease and Sarcoidosis, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Toby M Maher
- Hastings Centre for Pulmonary Research and Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jacky A Smith
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College, London, UK; Royal Brompton and Harefield Hospitals, London, UK.
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Abstract
In recent years, there has been a substantial increase in the development of antitussive therapies and the first new therapy, gefapixant has been licenced in Europe. This review describes current unlicenced treatments for chronic cough and details treatments currently in development for refractory chronic cough and cough in idiopathic pulmonary fibrosis, as well as compounds previously explored.
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Affiliation(s)
- Jaclyn A Smith
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester and Manchester Academic Health Science Centre, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT, UK.
- Manchester University NHS Foundation Trust, Manchester, UK.
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Liu S, Ye X. Assessment and Management of Cough in Idiopathic Pulmonary Fibrosis: A Narrative Review. Lung 2023; 201:531-544. [PMID: 37934241 DOI: 10.1007/s00408-023-00653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and fatal disease with an unknown cause. It is characterized by symptoms such as cough and breathlessness, which significantly impact patients' quality of life. Cough, in particular, has emerged as a burdensome symptom for individuals with IPF. The etiology of cough in IPF patients is believed to be complex, involving factors related to the disease itself, such as increased sensitivity of cough nerves, lung structural changes, inflammation, and genetic factors, as well as comorbidities and medication effects. Unfortunately, effective treatment options for cough in IPF remain limited, often relying on empirical approaches based on studies involving chronic cough patients in general and the personal experience of physicians. Medications such as opioids and neuromodulators are commonly prescribed but have shown suboptimal efficacy, imposing significant physical, psychological, and economic burdens on patients. However, there is hope on the horizon, as specific purinergic P2 receptor ligand-gated ion channel (P2X3) inhibitors have demonstrated promising antitussive effects in ongoing clinical trials. This review aims to provide a comprehensive overview of the evaluation and management of cough in IPF patients, as well as highlight emerging pharmacological and non-pharmacological approaches that target the cough reflex and are currently being investigated in clinical settings.
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Affiliation(s)
- Shangxiang Liu
- Department of Intensive Care Medicine, Nanjing Jiangbei Hospital, Nanjing, China
| | - Xu Ye
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 321 Zhongshan Road, Nanjing, China.
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Hirons B, Rhatigan K, Kesavan H, Turner RD, Birring SS, Cho PSP. Cough in chronic lung disease: a state of the art review. J Thorac Dis 2023; 15:5823-5843. [PMID: 37969279 PMCID: PMC10636467 DOI: 10.21037/jtd-22-1776] [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: 12/08/2022] [Accepted: 09/01/2023] [Indexed: 11/17/2023]
Abstract
Chronic cough (CC; ≥8 weeks in duration) is a common and burdensome feature of respiratory diseases. The understanding of cough has progressed significantly in recent years, albeit largely in refractory (unexplained) chronic cough (RCC) in the absence of other respiratory conditions. The prevalence of CC in respiratory diseases is poorly described, but estimates have been reported: asthma (8-58%), chronic obstructive pulmonary disease (COPD; 10-74%), bronchiectasis (82-98%), interstitial lung disease (ILD; 50-89%) and sarcoidosis (3-64%). CC in respiratory conditions generally predicts impaired health status and more severe disease. It is associated with increased symptom burden and disease severity in asthma, COPD, bronchiectasis and ILD, higher exacerbation frequency in asthma and bronchiectasis, and increased mortality and lung transplantation in idiopathic pulmonary fibrosis (IPF). Physiologically, heightened cough reflex sensitivity (CRS) has been reported and postulated to be mechanistic in isolated RCC. Cough reflex hypersensitivity (CRH) has also been reported in asthma, COPD, bronchiectasis, ILD and sarcoidosis. Unlike recent advances in isolated RCC, there are limited studies and understanding of central cough neuropathways in other respiratory conditions. Of note, dysfunctional central voluntary cough suppression neuropathways and physiology were observed in isolation in RCC; cough suppression is preserved in COPD. Understanding in the mechanism of RCC cannot be simply extrapolated to other respiratory conditions. The restricted understanding of cough mechanisms in these conditions has limited cough-specific therapeutic options in this context. There is currently an unmet need to expand our understanding of cough in chronic respiratory conditions, both in order to improve the quality of life of patients, and to improve knowledge of cough in general. This review aims to describe the prevalence, impact, pathophysiology and management of CC in asthma, COPD, bronchiectasis, ILD and sarcoidosis.
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Affiliation(s)
- Barnaby Hirons
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Katherine Rhatigan
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Harini Kesavan
- Department of Respiratory Medicine, King’s College Hospital, London, UK
| | - Richard D. Turner
- Department of Respiratory Medicine, Gold Coast University Hospital, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Surinder S. Birring
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Peter S. P. Cho
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
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Saunders P, Wu Z, Fahy WA, Stewart ID, Saini G, Smith DJF, Braybrooke R, Stock C, Renzoni EA, Johnson SR, Jenkins RG, Belvisi MG, Smith JA, Maher TM, Molyneaux PL. The Burden and Impact of Cough in Patients with Idiopathic Pulmonary Fibrosis: An Analysis of the Prospective Observational PROFILE Study. Ann Am Thorac Soc 2023; 20:1267-1273. [PMID: 37159951 PMCID: PMC10502892 DOI: 10.1513/annalsats.202302-174oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/09/2023] [Indexed: 05/11/2023] Open
Abstract
Rationale: Cough is a commonly reported symptom in idiopathic pulmonary fibrosis (IPF) that negatively impacts patient-reported quality of life (QoL). However, both the burden of cough at diagnosis and the behavior of cough over time have not been systematically described in patients with IPF. Objectives: By utilizing data prospectively collected as part of the PROFILE study, we sought to assess cough burden and the impact that this has on QoL within a cohort of patients with newly diagnosed IPF. We also reexamined the previously described relationship between cough and mortality and the association of cough with the MUC5B promoter polymorphism. Methods: The PROFILE study is a multicenter, prospective, observational, longitudinal cohort study of incident IPF. Scores on the Leicester Cough Questionnaire (LCQ) were recorded at baseline in 632 subjects and then repeated 6 monthly in a subset (n = 216) of the cohort. Results: The median LCQ score at diagnosis was 16.1 (interquartile range, 6.5). LCQ scores remained stable over the subsequent year in the majority of patients. There was a weak association between LCQ score and baseline lung function, with worse cough-related QoL associated with more severe physiological impairment. Cough scores were not associated with subsequent mortality after correcting for baseline lung function. Furthermore, there was no relationship between LCQ score and MUC5B promoter polymorphism status. Conclusions: The burden of cough in IPF is high. Although cough is weakly associated with disease severity at baseline, cough-specific QoL, as measured by the LCQ, confers no prognostic value. Cough-specific QoL burden remains relatively stable over time and does not associate with MUC5B promoter polymorphism.
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Affiliation(s)
- Peter Saunders
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Zhe Wu
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - William A. Fahy
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Iain D. Stewart
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Gauri Saini
- Centre for Respiratory Research, NIHR Biomedical Research Centre, Translational Medical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - David J. F. Smith
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Rebecca Braybrooke
- Centre for Respiratory Research, NIHR Biomedical Research Centre, Translational Medical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Carmel Stock
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Elisabetta A. Renzoni
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Simon R. Johnson
- Centre for Respiratory Research, NIHR Biomedical Research Centre, Translational Medical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - R. Gisli Jenkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Maria G. Belvisi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Jaclyn A. Smith
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, United Kingdom
| | - Toby M. Maher
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Hastings Centre for Pulmonary Research and Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Philip L. Molyneaux
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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Trachalaki A, Sultana N, Wells AU. An update on current and emerging drug treatments for idiopathic pulmonary fibrosis. Expert Opin Pharmacother 2023:1-18. [PMID: 37183672 DOI: 10.1080/14656566.2023.2213436] [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: 05/16/2023]
Abstract
INTRODUCTION Idiopathic Pulmonary Fibrosis (IPF) is a progressive and devastating lung disease, characterized by progressive lung scarring. AREAS COVERED Prior to antifibrotic therapy (pirfenidone and nintedanib), there was no validated pharmaceutical therapy for IPF. Both antifibrotics can slow disease progression, however, IPF remains a detrimental disease with poor prognosis and treated survival rates of less than 7 years from diagnosis. Despite their effect the disease remains non-reversible and progressing whilst their side effect profile is often challenging. Treatment of comorbidities is also crucial. In this review, we discuss the current pharmacological management as well as management of comorbidities and symptoms. We also reviewed clinicaltrials.gov and summarised all the mid to late stage clinical trials (phase II and III) registered in IPF over the last 7 years and discuss the most promising drugs in clinical development. EXPERT OPINION Future for IPF management will need to focus on current unresolved issues. First a primary pathogenetic pathway has not been clearly identified. Future management may involve a combination of brushstroke approach with antifibrotics with targeted treatments for specific pathways in patient subsets following an 'oncological' approach. Another unmet need is management of exacerbations, which are deathly in most cases as well as either treating or preventing lung cancer.
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Affiliation(s)
- Athina Trachalaki
- The Margaret Turner Warwick Centre for Fibrosing Lung Diseases, Imperial College London National Heart and Lung Institute, Imperial College, London, UK
- Imperial College NHS Hospitals, London UK
| | | | - Athol Umfrey Wells
- Interstitial Lung Disease Unit, Royal Brompton & Harefield Hospitals, London, UK
- The Margaret Turner Warwick Centre for Fibrosing Lung Diseases, Imperial College London National Heart and Lung Institute, Imperial College, London, UK
- Imperial College NHS Hospitals, London UK
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Tackling the Neuropathic Cough of Idiopathic Pulmonary Fibrosis (IPF): More Needs to be Done. Lung 2022; 200:673-675. [PMID: 36348052 DOI: 10.1007/s00408-022-00589-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
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