COPD in Asia: where East meets West

Awareness of COPD in low-and middle-income countries and implications for treatment

INTRODUCTION

COPD is the 3rd leading cause of death worldwide, affecting an estimated 212.3 million people. More than 80% of this burden occurs in low- and middle-income countries. One of the major reasons for this growing burden, is the lack of awareness of COPD among all levels.

AREAS COVERED

In this review article, we studied the level of awareness of COPD among lay people, health care providers and policy makers in the LMICs. Search engines including Google Scholar, PubMed, and Scopus were used for relevant articles. Articles spanning from 1990 to March 2024 were screened on COPD awareness in LMICs and its treatment implications using a combination of key words.

EXPERT OPINION

We report that the overall awareness of COPD is low at all levels. There are several reasons such as poverty, illiteracy, societal beliefs, cultural beliefs, and misconceptions. This is associated with increase in suffering, deaths, and economic loss, due to poor adaption correct prescription and compliance to treatment. And very little is being done to improve the current status. COPD needs to be highlighted in the national programs in LMICs.

The association between anti-smoking legislation and prevalence of acute respiratory illnesses in Indian children

Objective

Exposure to tobacco smoke causes numerous health problems in children, and create burden on the population in terms of economy, morbidity and mortality. In order to protect the child from exposure to tobacco smoke in the outdoor environment, sufficient legislative enactments are available in Indian legislation. The objective of the present study is to investigate the fact that in absence of any specific laws stating about protection of children from exposure to tobacco smoke in indoor environment, whether outdoor related legislations are sufficient to protect children from exposureand to explore the scope for enforcement of both state and central laws in improving health of children in India.

Study design

The study considered cross-sectional survey data of Demographic and Health Survey Data on India, National Family and Health Survey fourth round (NFHS-4) for the year 2015-16 on Indian children (below age of four).

Methods

Both bivariate and multivariate logistic regression models were used to assess the impact of anti-smoking laws on the prevalence of acute respiratory infection (ARI) based on the place of residence, indoor tobacco smoke exposure and age of the child.

Results

The results have shown an inclination of ARI among children in association with states having single law, rural area resident, exposure to indoor tobacco smoke and age of the child, both as independent or in combination are quite conspicuous, and are found to be underestimated. The logistic regression also revealed the influence of these factors both as independent and even in interaction with other.

Conclusions

Legislative intervention through both at central (or national)and state levels through anti-smoking laws will decrease the indoor tobacco smoke exposure as a result ARI prevalence will also decrease among children in India.

Risk of Death and Cardiovascular Events in Asian Patients With Atrial Fibrillation and Chronic Obstructive Pulmonary Disease: A Report From the Prospective APHRS Registry

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of adverse events in patients with atrial fibrillation (AF); however, few data are available on this topic in Asian populations.

METHODS AND RESULTS

Prospective observational study conducted on patients with AF enrolled in the Asia-Pacific Heart Rhythm Society (APHRS) AF Registry. The diagnosis of COPD was based on data reported in the case report form by the investigators. Cox-regression models were used to assess the 1-year risk of a primary composite outcome of all-cause death, thromboembolic events, acute coronary syndrome, and heart failure. Analysis on single outcomes and cardiovascular death was also performed. Interaction analysis was used to assess the risk of composite outcome and all-cause death in different subgroups. The study included 4094 patients with AF (mean±SD age 68.5±12 years, 34.6% female), of whom 112 (2.7%) had COPD. Patients with COPD showed a higher incidence of the primary composite outcome (25.1% versus 6.3%, P<0.001), all-cause death (14.9% versus 2.6%, P<0.001), cardiovascular death (2.0% versus 0.6%, P<0.001), and heart failure (8.3% versus 6.0%, P<0.001). On multiple Cox-regression analysis, COPD was associated with a higher risk of the primary composite outcome (hazard ratio [HR], 3.17 [95% CI, 2.05-4.90]), all-cause death (HR, 3.59 [95% CI, 2.04-6.30]), and heart failure (HR, 3.32 [95% CI, 1.56-7.03]); no statistically significant differences were found for other outcomes. The association between COPD and mortality was significantly modified by the use of beta blockers (Pint=0.018).

CONCLUSIONS

In Asian patients with AF, COPD is associated with worse prognosis. In patients with AF and COPD, the use of beta blockers was associated with a lower mortality.

REGISTRATION INFORMATION

clinicaltrials.gov Identifier: NCT04807049.

Sociodemographic correlates with prevalence of comorbidities in patients with chronic obstructive pulmonary disease: a study from a Chinese National Survey

Background

An increase in the prevalence of comorbidities has been reported in patients with chronic obstructive pulmonary disease (COPD). However, contemporary estimates of the overall prevalence of the sociodemographic correlates of COPD comorbidities are scarce and inconsistent in China. This study aimed to investigate the prevalence of sociodemographic correlates of comorbidities in patients with COPD across China.

Methods

This was a cross-sectional study. We used data from the Enjoying Breathing Program between May 2020 and April 2022. Participants with COPD from 17 provinces (or equivalent) were included. Comorbidity clusters were stratified based on the number of comorbidities per person. Univariable and multivariable analyses were used to determine the sociodemographic associations of patients with COPD with specific clusters of comorbidities after adjusting for age, sex, and other prespecified covariates. Tetrachoric correlation analyses were performed to determine the associations between specific comorbidities.

Findings

A total of 3913 participants with COPD were included, of whom 1744 (44.7%) had at least one comorbidity; 25.4% had one comorbid disease, 12.9% had two, and 6.4% had three or more concurrent diseases. The most common comorbidities were hypertension (17.8%), asthma (9.9%), bronchiectasis (8.2%), diabetes (8.2%), and coronary artery disease (7.7%). In the logistic regression models adjusted for a broad set of factors, patients with COPD residing in the east region of China and having health insurance experienced a decreased likelihood of comorbidities (from OR = 0.70 [95% confidence interval [CI], 0.53-0.93] to OR = 0.50 [95% CI, 0.25-0.99]). However, patients over 80 years had increased risk (OR 1.43 [95% CI 1.01-2.03]), as did those in all Modified Medical Research Council (mMRC) grade categories (grade 1: OR = 1.30 [95% CI, 1.02-1.65]; grade 2: OR = 1.39 [95% CI, 1.07-1.8]; grade 3: OR = 1.67 [95% CI, 1.23-2.26]; and grade 4: OR = 1.81 [95% CI, 1.00-3.28]) and in Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2 classification (OR = 1.30 [95% CI, 1.03-1.65]) relative to their respective references. The associations observed in these subgroups were consistent regardless of the number of comorbidities per person. Tetrachoric correlations demonstrated negative associations in pairwise comparisons of the top five comorbidities, ranging from -0.03 to -0.31 (p < 0.001 in all groups).

Interpretation

In China, comorbidities are highly prevalent among patients with COPD, with older age, higher mMRC grade, and lung function decline being the major risk factors. Studies with larger sample sizes are required to elucidate the complex mechanisms underlying COPD comorbidities.

Funding

This study was funded by CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-049 and 2022-I2M-C&T-B-107).

Do deaths from competing risks influence COPD patterns in China and high socio-demographic index countries?: a cross-sectional analysis of summary statistics from the Global Burden of Disease Study 2017

OBJECTIVE

To explore possible reasons for the difference in chronic obstructive pulmonary disease (COPD) incidence/mortality rates between China and high socio-demographic index (SDI) countries.

DESIGN

A cross-sectional analysis of summary statistics from the Global Burden of Disease Study 2017.

PARTICIPANTS

Data were publicly available and de-identified, and individuals were not involved.

MEASUREMENT AND METHODS

We extracted the age-standardised and age-specific incidence/mortality rates, and risk factors attributed to COPD in China and high SDI countries from the Global Burden of Disease Study 2017. We first described differences in COPD patterns (ie, incidence and mortality rates) in China and high SDI countries briefly, and then explored possible reasons for driving such differences by comparing rankings for six well-established COPD risk factors and estimating change points in age-specific incidence and mortality rates for COPD and several commonly encountered competing risks using segmented regression models.

RESULTS

Differences in age-standardised incidence and mortality rates for COPD between China and high SDI countries converged during 1990-2017 but still differed, particularly for mortality rates. Smoking was the leading attributable risk factor followed by ambient air pollution, with higher rankings for occupational risks in China than in high SDI countries. The change point was ~80 years for age-specific COPD mortality rate in both China and high SDI countries. However, the change point for COPD incidence was 5-year later in China (~65 years) than in high SDI countries (~60 years). The change points for mortality rates due to competing risks (eg, ischaemic heart disease) also varied between settings.

CONCLUSION

Differences in risk factors largely shaped the differences in COPD patterns between China and high SDI countries. Varying patterns of mortality due to competing risks might also contribute to the discrepancy in COPD mortality rates, by affecting the survival of the underlying population.

Review of Ground-Level Ozone Impact in Respiratory Health Deterioration for the Past Two Decades

Background: Ground-level ozone has been gaining notoriety with increasing evidence of its nefarious effects on health, especially respiratory diseases. Where do we stand on the solidity of this data and is there room for improvement? Objectives: Evaluate this evidence for incongruities or heterogeneity in this field of research. How is the exposure assessment conducted, where does Portugal stand in this field, and what can be improved? Health deterioration concerning asthma, chronic obstructive pulmonary disease (COPD), and acute respiratory distress syndrome (ARDS) are analysed. Methods: A review of 1735 studies was conducted through PubMed and Google Scholar engines for the past two decades. We identified 59 eligible studies and included an array of variables, including O3 measurements, number of air-quality monitoring stations used, relative risks, odds ratios, hazard ratios, number of hospital admissions, visits, or mortality, and size of population dataset used. Results: Approximately 83% of data in this review presents significant correlations of ozone with asthma, COPD, and ARDS. Studies that report negative or not significant associations mention a lack of data or topographic differences as the main issue with these divergent results. Studies consistently report summer as a period of particular concern. Portuguese data in this field is lacking. Conclusions: This research field is growing in interest and there is evidence that ozone plays a non-negligible role in health deterioration. The few Portuguese studies in this field seem aligned with the literature reviewed but more research is needed. Suggested improvements are more and better data through denser air-quality networks to accurately depict personal exposure to ozone. Homogenization of the exposure assessment concerning averaging times of ozone to daily maximum 8 h averages whenever possible. Risk increments based on 10 ppb instead of interquartile ranges. Lastly, contrary to some studies in this review, the topographic effect on concentrations and health deterioration should not be underestimated and seasonality should always be checked.

Development and validation of a prediction index for recent mortality in advanced COPD patients

The primary barrier to initiating palliative care for advanced COPD patients is the unpredictable course of the disease. We enroll 752 COPD patients into the study and validate the prediction tools for 1-year mortality using the current guidelines for palliative care. We also develop a composite prediction index for 1-year mortality and validate it in another cohort of 342 patients. Using the current prognostic models for recent mortality in palliative care, the best area under the curve (AUC) for predicting mortality is 0.68. Using the Modified Medical Research Council dyspnea score and oxygen saturation to define the combined dyspnea and oxygenation (DO) index, we find that the AUC of the DO index is 0.84 for predicting mortality in the validated cohort. Predictions of 1-year mortality based on the current palliative care guideline for COPD patients are poor. The DO index exhibits better predictive ability than other models in the study.

Trend of Mortality and Years of Life Lost Due to Chronic Obstructive Pulmonary Disease in China and Its Provinces, 2005-2020

Background

To examine trends in chronic obstructive pulmonary disease (COPD) mortality and years of life lost (YLL) due to COPD for all provinces in China during 2005–2020.

Methods

Data for COPD mortality were derived from China National Mortality Surveillance System (NMSS). We analyzed the numbers and age-standardized rates of death and YLL due to COPD in China, during 2005–2020. We carried out decomposition analysis to analyze the drivers of change in COPD deaths during the study period.

Results

The age-standardized mortality rate of COPD in China decreased significantly from 99.5/100,000 in 2005 to 50.5/100,000 in 2020. Similar trend was seen in the age-standardized YLL rate. The mortality rate increased with age. During 2005–2020, the age-standardized mortality rate decreased in all provinces (except for Tibet) with the largest decline in Jilin (−77.8%), Henan (−68.4%) and Fujian (−67.1%). The decreased number of deaths was decomposed as population growth (8.5%) and population ageing (69.7%) with offset by decline of age-specific mortality (−87.5%).

Conclusion

COPD remains an important public health problem in China, though significant reductions of COPD mortality and YLL rate were observed. Vigorous prevention and control strategies should be enhanced to improve the quality of life of COPD patients and reduce the premature death caused by COPD in Chinese population.

Triple Versus Dual Combination Therapy in Chronic Obstructive Pulmonary Disease in Asian Countries: Analysis of the IMPACT Trial

INTRODUCTION

In the IMPACT trial, single-inhaler triple therapy fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) reduced moderate/severe exacerbation rates versus FF/VI or UMEC/VI dual therapy in patients with chronic obstructive pulmonary disease (COPD); however, pneumonia incidence was higher in FF-containing arms. As COPD is a growing problem in Asia, we compared the efficacy and safety of FF/UMEC/VI in Asia versus non-Asia regions.

METHODS

IMPACT was a double-blind, 52-week trial in symptomatic COPD patients with ≥ 1 moderate/severe exacerbation in the prior year. This pre-specified analysis evaluated the annual rate of moderate/severe exacerbations, change from baseline in trough forced expiratory volume in 1 s, and St George's Respiratory Questionnaire total score, mortality, and safety (including pneumonia) in Asia versus non-Asia regions.

RESULTS

The intent-to-treat population comprised 10,355 patients (Asia n = 1644 [16%]). Rate ratios (95% confidence intervals) for moderate/severe exacerbations with FF/UMEC/VI were 0.89 (0.76-1.05) versus FF/VI and 0.86 (0.71-1.04) versus UMEC/VI in Asia, and 0.84 (0.79-0.90) and 0.74 (0.68-0.80) in non-Asia. Efficacy of FF/UMEC/VI on other endpoints was similar in both regions. There was an increased incidence of investigator-reported pneumonia in patients in Asia (FF/UMEC/VI: 13%; FF/VI: 14%; UMEC/VI: 6%) compared with non-Asia (FF/UMEC/VI: 6%; FF/VI: 5%; UMEC/VI: 4%). The increased risk of pneumonia in patients in Asia was most marked in patients with lower body mass index, lower lung function, and taking inhaled corticosteroids. In post hoc analysis of adjudicated on-treatment all-cause mortality, probabilities of death were numerically lower in both regions with FF/UMEC/VI (Asia: 1.16%; non-Asia: 1.35%) and FF/VI (Asia: 1.77%; non-Asia: 1.21%) versus UMEC/VI (Asia: 1.91%; non-Asia: 2.23%).

CONCLUSIONS

FF/UMEC/VI provides similar benefits in COPD patients in Asia and non-Asia regions. Clinical benefits of treatment, including reduction in mortality risk, should be weighed against risk of pneumonia, taking account of all known risk factors.

TRIAL REGISTRATION

ClinicalTrials.gov identification, NCT02164513.

Chronic respiratory disease mortality and its associated factors in selected Asian countries: evidence from panel error correction model

Background

Chronic Respiratory Diseases (CRDs) in Asian countries are a growing concern in terms of morbidity and mortality. However, a systematic understanding of the increasing age-adjusted mortality rate of chronic respiratory disease (CRD) and its associated factors is not readily available for many Asian countries. We aimed to determine country-level factors affecting CRD mortality using a panel error correction model.

Methods

Based on data from the Global Burden of Disease Study 2017, we estimated the trends and distribution of CRD mortality for selected Asian countries from 2010 to 2017. Furthermore, we evaluated the relationship between CRD mortality and Gross Domestic Product (GDP) per capita, average years of schooling, urbanization, and pollutant emission (PM2.5 concentration) using a fixed-effect model. We corrected the estimates for heteroscedasticity and autocorrelation through Prais-Winsten adjustment along with robust standard error.

Results

Between 2010 and 2017, approximately 21.4 million people died from chronic respiratory diseases in the countries studied. Age-standardized crude mortality rate from CRDs in the period had minimum and maximum values of 8.19 (Singapore in 2016) and 155.42 (North Korea in 2010) per 100,000 population, respectively. The coefficients corrected for autocorrelation and heteroskedasticity based on the final model of our study (Prais-Winsten), showed that all explanatory variables were statistically significant (p < 0.001). The model shows that the 1% increase in GDP per capita results in a 20% increase (0.203) in the CRD mortality rate and that a higher concentration of air pollution is also positively associated with the CRD deaths (0.00869). However, an extra year of schooling reduces the mortality rate by 4.79% (− 0.0479). Further, rate of urbanization is negatively associated with the CRD death rate (− 0.0252).

Conclusions

Our results indicate that both socioeconomic and environmental factors impact CRD mortality rates. Mortality due to CRD increases with rising GDP per capita and decreases with the percentage of the total population residing in urban areas. Further, mortality increases with greater exposure to PM2.5. Also, higher years of schooling mitigate rising CRD mortality rates, showing that education can act as a safety net against CRD mortality. These results are an outcome of sequential adjustments in the final model specification to correct for heteroscedasticity and autocorrelation.

"High-Risk" Clinical and Inflammatory Clusters in COPD of Chinese Descent

BACKGROUND

COPD is a heterogeneous disease demonstrating inter-individual variation. A high COPD prevalence in Chinese populations is described, but little is known about disease clusters and prognostic outcomes in the Chinese population across Southeast Asia. We aim to determine if clusters of Chinese patients with COPD exist and their association with systemic inflammation and clinical outcomes.

RESEARCH QUESTION

We aim to determine if clusters of Chinese patients with COPD exist and their association with clinical outcomes and inflammation.

STUDY DESIGN AND METHODS

Chinese patients with stable COPD were prospectively recruited into two cohorts (derivation and validation) from six hospitals across three Southeast Asian countries (Singapore, Malaysia, and Hong Kong; n = 1,480). Each patient was followed more than 2 years. Clinical data (including co-morbidities) were employed in unsupervised hierarchical clustering (followed by validation) to determine the existence of patient clusters and their prognostic outcome. Accompanying systemic cytokine assessments were performed in a subset (n = 336) of patients with COPD to determine if inflammatory patterns and associated networks characterized the derived clusters.

RESULTS

Five patient clusters were identified including: (1) ex-TB, (2) diabetic, (3) low comorbidity: low-risk, (4) low comorbidity: high-risk, and (5) cardiovascular. The cardiovascular and ex-TB clusters demonstrate highest mortality (independent of Global Initiative for Chronic Obstructive Lung Disease assessment) and illustrate diverse cytokine patterns with complex inflammatory networks.

INTERPRETATION

We describe clusters of Chinese patients with COPD, two of which represent high-risk clusters. The cardiovascular and ex-TB patient clusters exhibit high mortality, significant inflammation, and complex cytokine networks. Clinical and inflammatory risk stratification of Chinese patients with COPD should be considered for targeted intervention to improve disease outcomes.

Association Between Adherence to Maintenance Medication in Patients with COPD and Acute Exacerbation Occurrence and Cost in China: A Retrospective Cohort Database Study

Background

This study aimed to evaluate the association between adherence to maintenance medication (ie, inhaled bronchodilators, inhaled corticosteroid/long-acting beta-2 agonist [ICS/LABA] combinations, and oral therapy) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and related costs among patients with chronic obstructive pulmonary disease (COPD) in China.

Patients and Methods

Claims data from the hospitals of a metropolitan city in south China between January 2014 and December 2016 were obtained. Patients with COPD with ≥2 maintenance medication claims during 1 year were included. Adherence was measured by the proportion of days covered (PDC). The interaction of medication class×adherence was considered when building models.

Results

A total of 11,708 patients met the inclusion criteria, of whom 10.8% were highly adherent (PDC≥0.8). There were significant interaction effects of drug category on hospitalized AECOPD risk (P≤0.001), hospitalized AECOPD rate (P<0.001), and 1-year hospitalized AECOPD treatment costs (P=0.012). There was a relationship between high adherence and outcomes for ICS/LABA combinations (n=3,419), ie, relative risk of hospitalized AECOPD was reduced by 34.8% (adjusted odds ratio=0.65; 95% confidence interval (CI): 0.54–0.79; P<0.001) while the frequency of hospitalized AECOPD per patient-year was reduced by 24.4% (adjusted rate ratio=0.76; 95% CI: 0.65 to 0.87; P<0.001). Mean 1-year per-patient hospitalized AECOPD costs were reduced by 37.8% (mean difference=−848 USD; 95% CI: −1435–262 USD; P<0.001). Patients taking oral mucolytics and having high adherence had worse AECOPD outcomes than patients with poor adherence.

Conclusion

High adherence to ICS/LABA maintenance therapy was associated with reduced hospitalized AECOPD rates and costs in Chinese patients with COPD.

Efficacy and Safety of Once-Daily Inhaled Umeclidinium in Asian Patients with COPD: Results from a Randomized, Placebo-Controlled Study

Purpose

Previous studies demonstrating efficacy and safety of once-daily umeclidinium (UMEC) in patients with chronic obstructive pulmonary disease (COPD) have included few Asian patients. This study evaluated efficacy and safety of UMEC 62.5 mcg versus placebo in Asian patients with COPD.

Patients and Methods

A Phase III, randomized, double-blind, parallel-group study. Patients (aged ≥40 years with COPD, pre-, and post-albuterol forced expiratory volume in 1 s [FEV1]/forced vital capacity ratio <0.70 and low risk of exacerbations) were randomized 2:1 to once-daily UMEC 62.5 mcg or placebo via the ELLIPTA inhaler for 24 weeks. Primary endpoint was change from baseline (CFB) in trough FEV1 on Day 169. Secondary endpoints were weighted mean FEV1 over 0-6 hrs post-dose on Day 1 and CFB in Transition Dyspnea Index (TDI) focal score on Day 168.

Results

A total of 306 patients were included in the modified intent-to-treat population (UMEC: 205; placebo: 101). UMEC versus placebo provided a statistically significant improvement in least squares (LS) mean trough FEV1 between baseline and Day 169 (154 mL [95% confidence interval (CI): 113, 194]; p<0.001). A clinically meaningful difference of 125 mL in favor of UMEC (95% CI: 103, 147; p<0.001) was also seen in LS weighted mean FEV1 0-6 hrs post-dose on Day 1. A LS mean treatment difference in TDI focal score of 0.9 units in favor of UMEC was seen on Day 168 (95% CI: 0.3, 1.5; p=0.004). Incidence of on-treatment adverse events (AEs) was lower in the placebo (55%) versus UMEC arm (60%); non-fatal serious AEs, drug-related AEs, and AEs leading to withdrawal were similar with UMEC and placebo.

Conclusion

Once-daily UMEC 62.5 mcg resulted in statistically significant and clinically meaningful improvements in lung function and dyspnea, compared with placebo, in Asian patients with COPD, with no new safety concerns observed.

Air Pollution in a Nationally Representative Sample: Findings from the National Adult Tobacco Survey of Lao PDR

In Southeast Asia, household air pollution (HAP) from solid fuel use is the leading cause of disability-adjusted life years (DALYs), a risk which is compounded by exposure to other sources of indoor and outdoor air pollution including secondhand tobacco smoke (SHS). The purpose of this study was to measure the individual and combined prevalence of exposure to household and community sources of air pollution in a national sample of adults in Lao PDR. We analyzed data from the 2012 National Adult Tobacco Survey (NATSL) of Lao PDR-a multi-stage stratified cluster sample of 9706 subjects from 2822 households located in all 17 provinces. Our findings indicate a high prevalence of exposure to household air pollution from cooking fires (78%) and SHS exposure in the home (74.5%). More than a third (32.8%) reported exposure to both inside the home. Exposure to outdoor sources of smoke from cooking, trash, and crop fires was substantial (30.1% to 56.0%). The aggregation of exposures from multiple sources of household air pollution raises the need for initiatives that establish programmatic linkages in the health, environmental, and agricultural sectors to provide a comprehensive strategy to reduce risk factors for respiratory disease in Lao PDR and the region.

Comparison of clinical baseline characteristics between Asian and Western COPD patients in a prospective, international, multicenter study

We aimed to compare clinical characteristics between Asian and Western chronic obstructive pulmonary disease (COPD) patients. This was a sub-analysis of an international, multicenter, prospective cohort study. Asian patients were enrolled in Singapore and South Korea. Western patients were enrolled in Spain, Poland, Ireland, the United Kingdom, and Malta. A total of 349 patients were analyzed. Among them, 110 (32%) patients were Asian and 239 (68%) Western. Male sex was more predominant in Asian than in Western (95% versus 63%, respectively; P<0.01). Body mass index was significantly lower in Asian (23.5 versus 27.1; P<0.01). The proportion of patients with a history of exacerbation was lower in Asian (12% versus 64%; P<0.01). Although patients were enrolled by same inclusion criteria, there were several differences between Asian and Western COPD patients. Our study has shown unbiased real-world differences between Asian and Western COPD patients. Since prospective follow-up study is currently ongoing, the result of this study can be fundamental base of future analysis.

Management of COPD in Asia: A position statement of the Asian Pacific Society of Respirology

Chronic obstructive pulmonary disease (COPD) is a major disease in Asia. However, how to manage specifically Asian COPD patients has not been proposed. Awareness of COPD is very low and underdiagnosis/undertreatment is common in Asian countries. Low utilization of pulmonary function test and inhalers is also a problem. Moreover, high smoking prevalence and air pollution are barriers to managing Asian patients with COPD. The relatively low body mass index of Asian patients with COPD can increase their risk for experiencing adverse effects from COPD drugs. Physicians should consider the unique features of Asian populations with COPD such as the high prevalence rates of bronchiectasis and tuberculosis-destroyed lungs, biomass smoke exposure and parasitic infection.

Clinical characteristics of pulmonary hypertension patients living in plain and high-altitude regions

OBJECTIVE

The demographic characteristics, ratio of aetiologies and biochemical parameters of adult patients with pulmonary hypertension (PH) living in plain and high-altitude regions were investigated and analysed.

METHODS

In total, 2846 adult patients with PH hospitalized from 2010 to 2015 in the Second Xiangya Hospital of Central South University and Qinghai Red Cross Hospital were retrospectively investigated.

RESULTS

(1) In the present study, the numbers of patients with PH in both the plain and high-altitude regions increased annually (P < 0.05), and the in-hospital prevalence of PH significantly increased over time in the high-altitude region. PH was more common in women in the plain region. Furthermore, compared with PH patients living in the plain region, those living in the high-altitude region were older (P < 0.05) and had higher smoking rates (P < 0.05). In the plain region, the greatest proportion of patients with PH belonged to group 2 (PH because of left heart disease), while in the high-altitude region, group 3 (PH because of lung diseases and/or hypoxia) was the most common (P < 0.05). (2) Haemoglobin levels, red blood cell counts, mean platelet volumes and platelet volume distribution widths were lower in PH patients living in the plain region than in those living in the high-altitude region. Furthermore, platelet counts were higher in patients living in the plain region than in those living in the high-altitude region (P < 0.05). The BNP/NT-proBNP levels were higher in PH patients living in the plain region (45.5%), which were mostly in group 4, than in those living the high-altitude region (P < 0.05).

CONCLUSIONS

The data from the hospitals in both the plain and high-altitude regions show a tendency towards increased in-hospital prevalence of PH over the last 6 years. The most common aetiologies of PH in patients living in the plain region and high-altitude regions were left heart disease and lung disease, respectively. Compared with PH patients living in the plain region, those living in the high-altitude region had better cardiac function and less severe PH.

Validation of the GOLD 2017 and new 16 subgroups (1A-4D) classifications in predicting exacerbation and mortality in COPD patients

BACKGROUND AND OBJECTIVE

A multidimensional assessment of COPD was recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2013 and revised in 2017. We examined the ability of the GOLD 2017 and the new 16 subgroup (1A-4D) classifications to predict clinical outcomes, including exacerbation and mortality, and compared them with the GOLD 2013 classifications.

METHODS

Patients with COPD were recruited from January 2006 to December 2017. The predictive abilities of grades 1-4 and groups A-D were examined through a logistic regression analysis with receiver operating curve estimations and area under the curve (AUC).

RESULTS

A total of 553 subjects with COPD were analyzed. The mortality rate was 48.6% during a median follow-up period of 5.2 years. Both the GOLD 2017 and the 2013 group A-D classifications had good predictive ability for total and severe exacerbations, for which the AUCs were 0.79 vs 0.77 and 0.79 vs 0.78, respectively. The AUCs for the GOLD 2017 groups A-D, grades 1-4, and the GOLD 2013 group A-D classifications were 0.70, 0.66, and 0.70 for all-cause mortality and 0.73, 0.71, and 0.74 for respiratory cause mortality, respectively. Combining the spirometric staging with the grouping for the GOLD 2017 subgroups (1A-4D), the all-cause mortality rate for group B and D patients was significantly increased from subgroups 1B-4B (27.7%, 50.6%, 53.3%, and 69.2%, respectively) and groups 1D-4D (55.0%, 68.8%, 82.1%, and 90.5%, respectively). The AUCs of subgroups (1A-4D) were 0.73 and 0.77 for all-cause and respiratory mortality, respectively; the new classification was determined more accurate than the GOLD 2017 for predicting mortality (P<0.0001).

CONCLUSION

The GOLD 2017 classification performed well by identifying individuals at risk of exacerbation, but its predictive ability for mortality was poor among COPD patients. Combining the spirometric staging with the grouping increased the predictive ability for all-cause and respiratory mortality.

SUMMARY AT A GLANCE

We validate the ability of the GOLD 2017 and 16 subgroup (1A-4D) classifications to predict clinical outcome for COPD patients. The GOLD 2017 classification performed well by identifying individuals at risk of exacerbation, but its predictive ability for mortality was poor. The new 16 subgroup (1A-4D) classification combining the spirometric 1-4 staging and the A-D grouping increased the predictive ability for mortality and was better than the GOLD 2017 for predicting all-cause and respiratory mortality among COPD patients.

A comparison of spatial heterogeneity with local cluster detection methods for chronic respiratory diseases in Thailand

Background: The Centers for Disease Control and Prevention reported that deaths from chronic respiratory diseases (CRDs) in Thailand increased by almost 13% in 2010, along with an increased burden related to the disease. Evaluating the geographical heterogeneity of CRDs is important for surveillance. Previous studies have indicated that socioeconomic status has an effect on disease, and that this can be measured with variables such as night-time lights (NTLs) and industrial density (ID). However, there is no understanding of how NTLs and ID correlate with CRDs. We compared spatial heterogeneity obtained by using local cluster detection methods for CRDs and by correlating NTLs and ID with CRDs.

Methods: We applied the spatial scan statistic in SaTScan, as well as local indices of spatial association (LISA), Getis and Ord’s local Gi*(d) statistic, and Pearson correlation. In our analysis, data were collected on gender, age, household income, education, family size, occupation, region, residential area, housing construction materials, cooking fuels, smoking status and previously diagnosed CRDs by a physician from the National Socioeconomic Survey, which is a cross-sectional study conducted by the National Statistical Office of Thailand in 2010.

Results: According to our findings, the spatial scan statistic, LISA, and the local Gi*(d) statistic revealed similar results for areas with the highest clustering of CRDs. However, the hotspots for the spatial scan statistic covered a wider area than LISA and the local Gi*(d) statistic. In addition, there were persistent hotspots in Bangkok and the perimeter provinces. NTLs and ID have a positive correlation with CRDs.

Conclusions: This study demonstrates that all the statistical methods used could detect spatial heterogeneity of CRDs. NTLs and ID can serve as new parameters for determining disease hotspots by representing the population and industrial boom that typically contributes to epidemics.

Study Design of VESUTO®: Efficacy of Tiotropium/Olodaterol on Lung Hyperinflation, Exercise Capacity, and Physical Activity in Japanese Patients with Chronic Obstructive Pulmonary Disease

Introduction

The superiority of tiotropium/olodaterol is demonstrated in improvement of lung function, dyspnea, lung hyperinflation, and quality of life compared with either monotherapy in patients with chronic obstructive pulmonary disease (COPD). Japanese Respiratory Society Guidelines for COPD management include improvement of exercise tolerance and daily physical activity as the treatment goals; however, there is limited evidence in Japanese patients with COPD.

Methods

A protocol is developed for the VESUTO^® study that investigates the efficacy of tiotropium/olodaterol fixed-dose combination (FDC) compared with tiotropium alone on inspiratory capacity (IC, volume from functional residual capacity to total lung capacity), exercise capacity, and daily physical activity in Japanese patients with COPD.

Results

A total of 180 Japanese patients with COPD, aged ≥40 years will be enrolled into the double-blind, multicenter, active-controlled, crossover study (NCT02629965) and will be randomized to receive either tiotropium/olodaterol FDC or tiotropium for 6 weeks each [two puffs via RESPIMAT^® (Boehringer Ingelheim, Ingelheim, Germany) inhaler in the morning]. The primary endpoint is IC at rest measured at 60 min post-dose after 6 weeks treatment. The secondary endpoints include the 6-min walk distance (6MWD) at 90 min post-dose and physical activity measured by the activity monitor in the last 2 weeks of the 6-week treatment periods. Lung function tests will also be assessed after 6 weeks treatment. A mixed-effects model repeated measures approach will be used for the primary and secondary endpoints.

Conclusion

The VESUTO^® study is the first randomized interventional study to investigate exercise capacity (6MWD) and physical activity measured by a 3-axis accelerometer in Japanese patients with COPD. The study could provide additional evidence of long-acting muscarinic antagonist (LAMA) + long-acting β₂-agonist (LABA) combination therapy on patients’ physical activities as well as lung function.

Trial registration

ClinicalTrials.gov: NCT02629965 (registered on December 1, 2015).

Funding

The VESUTO study was funded by Nippon Boehringer Ingelheim Co., Ltd., Tokyo, Japan.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-017-0554-3) contains supplementary material, which is available to authorized users.

Understanding COPD-overlap syndromes

INTRODUCTION

Chronic obstructive pulmonary disease accounts for a large burden of lung disease. It can 'overlap' with other respiratory diseases including bronchiectasis, fibrosis and obstructive sleep apnea (OSA). While COPD alone confers morbidity and mortality, common features with contrasting clinical outcomes can occur in COPD 'overlap syndromes'. Areas covered: Given the large degree of heterogeneity in COPD, individual variation to treatment is adopted based on its observed phenotype, which in turn overlaps with features of other respiratory disease states such as asthma. This is coined asthma-COPD overlap syndrome ('ACOS'). Other examples of such overlapping clinical states include bronchiectasis-COPD ('BCOS'), fibrosis-COPD ('FCOS') and OSA-COPD ('OCOS'). The objective of this review is to highlight similarities and differences between the COPD-overlap syndromes in terms of risk factors, pathophysiology, diagnosis and potential treatment differences. Expert commentary: As a consequence of COPD overlap syndromes, a transition from the traditional 'one size fits all' treatment approach is necessary. Greater treatment stratification according to clinical phenotype using a precision medicine approach is now required. In this light, it is important to recognize and differentiate COPD overlap syndromes as distinct disease states compared to individual diseases such as asthma, COPD, fibrosis or bronchiectasis.

Indacaterol/glycopyrronium versus salmeterol/fluticasone in Asian patients with COPD at a high risk of exacerbations: results from the FLAME study

Background

The FLAME study demonstrated that indacaterol/glycopyrronium (IND/GLY), the fixed-dose combination of a long-acting β₂-agonist (LABA, IND) and a long-acting muscarinic antagonist (LAMA, GLY), was superior to salmeterol/fluticasone combination (SFC) in preventing exacerbations in COPD patients with a high risk of exacerbations. In this study, we report a prespecified analysis of the efficacy and safety of IND/GLY versus SFC in Asian patients from the FLAME study.

Patients and methods

Patients from Asian centers with moderate-to-very severe COPD and ≥1 exacerbation in the previous year from the 52-week, randomized FLAME study were included. IND/GLY was compared versus SFC for effects on exacerbations, lung function (forced expiratory volume in 1 second [FEV₁] and forced vital capacity [FVC]), health status (St George’s Respiratory Questionnaire [SGRQ]), rescue medication use, and safety.

Results

A total of 510 Asian patients (IND/GLY, n=250 or SFC, n=260) were included. Compared to the overall FLAME population, the Asian cohort had more males, a shorter duration of COPD, fewer patients using inhaled corticosteroid (ICS) at screening, fewer current smokers, and more patients with very severe COPD. IND/GLY significantly reduced the rate of moderate/severe exacerbations (rate ratio: 0.75; 95% confidence interval: 0.58–0.97; P=0.027) and prolonged time to first moderate/severe exacerbation versus SFC (hazard ratio: 0.77; 95% confidence interval: 0.59–1.01; P=0.055). Predose trough FEV₁ and FVC significantly improved in Asian patients (P<0.001). IND/GLY improved SGRQ for COPD (SGRQ-C score; P=0.006) and reduced rescue medication use (P=0.058) at week 52. Pneumonia incidence was 3.6% with IND/GLY and 7.7% with SFC (P=0.046).

Conclusion

In exacerbating Asian COPD patients, IND/GLY was more effective than SFC.

Costs of chronic obstructive pulmonary disease in urban areas of China: a cross-sectional study in four cities

PURPOSE

The economic burden of COPD has not been well studied in China. This study investigated the total costs caused by COPD and the influencing factors for the high economic burden in urban areas of China.

PATIENTS AND METHODS

A cross-sectional study was carried out among 678 COPD patients in four cities in China in 2011. The average annual direct medical costs (DMCs), direct nonmedical costs (DNMCs), and indirect costs (ICs) on COPD were measured by median and mean (± standard deviation). Logistic regression model was used to explore factors related to high total costs on COPD.

RESULTS

The median annual DMCs, DNMCs, and ICs per COPD patient were RMB 5565 Yuan (US$ 862), 0 Yuan (US$ 0), and 0 Yuan (US$ 0), respectively, and the mean annual DMCs, DNMCs, and ICs per COPD patient were RMB 11968 (±22422) Yuan [US$ 1853 (±3472)], 539 (±2092) Yuan [US$ 83 (±324)], and 2087 (±8110) Yuan [US$ 323 (±1256)], respectively. The annual DMCs, DNMCs, and ICs for diagnosed COPD patients were RMB 195.70 billion Yuan (US$ 30.30 billion), 8.78 billion Yuan (US$ 1.36 billion), and 34.10 billion Yuan (US$ 5.28 billion), respectively, in China. Hospitalization accounted for 56.7% of the total costs. High economic burden was significantly related to age, acute exacerbations, and disease severity in COPD patients.

CONCLUSION

COPD posed a heavy economic burden in China. Measures to delay the disease progression and to reduce the risks of acute exacerbation and hospitalization will help substantially lower the costs for COPD care.

Pharmacokinetics of Roflumilast and Its Active Metabolite Roflumilast N-Oxide in Healthy Chinese Subjects After Single and Multiple Oral Doses

BACKGROUND AND OBJECTIVES

Roflumilast is a selective, oral phosphodiesterase 4 inhibitor approved for the treatment of severe chronic obstructive pulmonary disease. The aim of this study was to evaluate the pharmacokinetics of roflumilast and roflumilast N-oxide in healthy Chinese subjects, and the effects of gender and food on their respective pharmacokinetic profiles.

METHODS

36 healthy Chinese subjects were recruited in a randomized, single-center, open-label, parallel group study and assigned to 0.25-, 0.375-, and 0.5-mg dose groups. The single-dose pharmacokinetic studies in fasting condition were carried out in all groups. Moreover, the food effect study and multiple-dose study were conducted in 0.375-mg dose group. Serial blood samples were collected over 168 h after dosing, and plasma concentrations of roflumilast and roflumilast N-oxide were determined using a validated LC-MS/MS method.

RESULTS

After oral administration of single doses of 0.25, 0.375 and 0.5 mg of roflumilast under fasting condition, the mean AUC_0-72h for roflumilast was 21.7 ± 8.3, 29.8 ± 8.3 and 54.2 ± 21.3 ng·h/mL, respectively. Meanwhile the mean AUC_0-168h for roflumilast N-oxide was 290 ± 103, 385 ± 107 and 673 ± 245 ng·h/mL, respectively. In the steady state after the multi-dose administration, the exposure to roflumilast in the subjects increased 20-40 %, and the exposure to roflumilast N-oxide increased about 169 %, compared to the single-dose administration. No statistically significant effect of gender on the disposition of roflumilast and roflumilast N-oxide was observed. Food had no effect on systemic exposure to roflumilast and roflumilast N-oxide in the subjects, but delayed the T _max of roflumilast by 0.9 h and reduced the C _max of roflumilast by approximately 20 %.

CONCLUSION

Based upon between-study comparison, peak and systemic exposure of roflumilast and roflumilast N-oxide were higher in Chinese than that in Caucasian subjects after oral administration of the same dose (i.e., 0.25 and 0.5 mg). It implies that the therapeutic dose for Chinese patients may be different from that for Caucasians, warranting further investigation.

Efficacy and tolerability of budesonide/formoterol added to tiotropium compared with tiotropium alone in patients with severe or very severe COPD: A randomized, multicentre study in East Asia

BACKGROUND AND OBJECTIVE

Triple combination therapy with tiotropium plus budesonide/formoterol has improved lung function and reduced exacerbation risk in patients with chronic obstructive pulmonary disease (COPD) in Western countries, but no such data exist for East Asian patients. This study aimed to evaluate the efficacy and tolerability of adding budesonide/formoterol to tiotropium compared with tiotropium alone in East Asian patients with severe/very severe COPD.

METHODS

This 12-week, randomized, parallel-group, multicentre, open-label study was conducted in East Asia. After a 14-day run-in period during which patients received tiotropium 18 μg once daily, patients were randomized to tiotropium (18 μg once daily) + budesonide/formoterol (160/4.5 μg 2 inhalations twice daily) or tiotropium alone (18 μg once daily). The primary endpoint was change from baseline in pre-dose forced expiratory volume in 1 s (FEV1 ) to the mean of values measured at Weeks 1, 6 and 12.

RESULTS

Pre-dose FEV1 significantly increased from baseline with tiotropium plus budesonide/formoterol (n = 287) versus tiotropium alone (n = 291) (5.0% vs 0.6%; treatment difference: 4.4% (95% CI: 1.9-6.9), P = 0.0004). Triple therapy also reduced the COPD exacerbation rate by 40.7% (P = 0.0032) and prolonged time to first exacerbation (38.6% risk reduction, P = 0.0167) versus tiotropium alone and markedly improved health-related quality of life (HRQoL), measured using the St George's Respiratory Questionnaire. Incidence of adverse events was 26% for both groups.

CONCLUSIONS

In East Asian patients with severe/very severe COPD, adding budesonide/formoterol to tiotropium was associated with significant improvements in FEV1 and HRQoL and lower COPD exacerbation rates. Treatment was generally well tolerated.

CLINICAL TRIAL REGISTRATION

NCT01397890 at Clinicaltrials.gov.

Efficacy and safety of once-daily inhaled umeclidinium/vilanterol in Asian patients with COPD: results from a randomized, placebo-controlled study

Background

Combination of the inhaled long-acting muscarinic antagonist umeclidinium (UMEC; GSK573719) with the long-acting β₂-agonist vilanterol (VI) is an approved maintenance treatment for COPD in the US and EU. We compared the efficacy and safety of UMEC/VI with placebo in patients with COPD of Asian ancestry.

Patients and methods

In this 24-week, Phase III, multicenter, randomized, double-blind, placebo-controlled, parallel-group study, patients were randomized 1:1:1 to UMEC/VI 125/25 μg, UMEC/VI 62.5/25 μg, or placebo. The primary efficacy end point was trough forced expiratory volume in 1 second (FEV₁) on day 169; secondary end points were Transition Dyspnea Index (TDI) focal score at week 24 and weighted mean (WM) FEV₁ over 0–6 hours postdose on day 1. Additional end points and safety were also assessed.

Results

Both UMEC/VI 125/25 μg and UMEC/VI 62.5/25 μg statistically significantly improved trough FEV₁ at day 169 versus placebo (UMEC/VI 125/25 μg, 0.216 L, [95% confidence interval [CI] 0.175–0.257]; UMEC/VI 62.5/25 μg, 0.151 L, 95% CI 0.110–0.191; both P<0.001). Statistically significant improvements in TDI score were observed for both UMEC/VI groups versus placebo (UMEC/VI 125/25 μg, 0.9, 95% CI 0.3–1.4, P=0.002; UMEC/VI 62.5/25 μg, 0.7, 95% CI 0.1–1.2, P=0.016). On day 1, both UMEC/VI groups improved 0–6-hour WM FEV₁ versus placebo (UMEC/VI 125/25 μg, 0.182 L 95% CI 0.161–0.203; UMEC/VI 62.5/25 μg, 0.160 L, 95% CI 0.139–0.181; both P<0.001). Statistically significant improvements for UMEC/VI groups versus placebo were observed for rescue albuterol use at weeks 1–24 (puffs/day, both P<0.001). The incidence of adverse events was similar across groups.

Conclusion

In Asian patients with COPD, once-daily UMEC/VI 125/25 μg and UMEC 62.5/25 μg resulted in clinically meaningful and statistically significant improvements in lung-function end points versus placebo. Symptomatic and quality of life measures also improved. The safety profile of UMEC/VI was consistent with previous studies.

Fluoroquinolones versus β-Lactam/β-Lactamase Inhibitors in Outpatients with Chronic Obstructive Pulmonary Disease and Pneumonia: A Nationwide Population-Based Study

Background

Studies on the association between antibiotic treatment and outcomes in outpatients with chronic obstructive pulmonary disease (COPD) and pneumonia are scarce. This study aimed to evaluate the effectiveness of fluoroquinolones and β-lactam/β-lactamase inhibitors for pneumonia in COPD outpatients.

Methods

We conducted a retrospective cohort study and identified 4,851 episodes of pneumonia among COPD outpatients treated with fluoroquinolones or β-lactam/β-lactamase inhibitors from the Taiwan National Health Insurance Research Database during 2002–2011. Using the propensity score analysis, 1,296 pairs of episodes were matched for the demographic and clinical characteristics. The primary outcome was pneumonia/empyema-related hospitalization or emergency department (ED) visits, and the secondary outcomes were treatment failure, all-cause mortality and medical costs within 30 days.

Results

Compared with episodes treated with β-lactam/β-lactamase inhibitors, episodes treated with fluoroquinolones had similar clinical outcomes. The rates of pneumonia/empyema-related hospitalization or ED visits were 3.9% and 3.5% in the fluoroquinolone and β-lactam/β-lactamase inhibitor groups, respectively (adjusted hazard ratio [aHR], 1.11; 95% confidence interval [CI], 0.74–1.66). The percentage of treatment failure and all-cause mortality were 28.2% versus 31.3% (adjusted odds ratio, 0.86; 95% CI, 0.73–1.02) and 0.5% versus 0.4% (aHR, 1.40; 95% CI, 0.45–4.41) in the fluoroquinolone and β-lactam/β-lactamase inhibitor groups, respectively. The medical expenditures, including total medical costs (528 versus 455 US dollars) and pneumonia-related costs (202 vs. 155 USD) were also balanced between the two treatment groups (both P >0.05).

Conclusions

For pneumonia in COPD outpatients, fluoroquinolones were associated with similar clinical outcomes and medical expenditures compared with β-lactam/β-lactamase inhibitors.

Comorbidities in obstructive lung disease in Korea: data from the fourth and fifth Korean National Health and Nutrition Examination Survey

BACKGROUND

Comorbidities can occur frequently in patients with chronic obstructive pulmonary disease (COPD) and can influence mortality and morbidity independently. It is increasingly recognized that many patients with COPD have comorbidities that have a major impact on their quality of life and survival. Therefore, we investigated the prevalence of comorbidities in Korean COPD populations.

METHODS

We used data obtained in the 6 years of the fourth and fifth Korean National Health and Nutrition Examination Survey (KNHANES) IV and V. Among 50,405 subjects, 16,151 subjects aged ≥40 years who performed spirometry adequately were included in this study. Airway obstruction was defined as forced expiratory volume in 1 second/forced vital capacity <0.7, and the Global Initiative For Chronic Obstructive Lung Disease stage was used to evaluate the severity of airway obstruction. Statistical analyses were performed using SAS 9.2.

RESULTS

Among the 16,151 subjects (43.2% male, 56.8% female; mean age: 57.1 years for men and 57.2 years for women), 13.1% had obstructive lung function; 11.3%, restrictive lung function; and 75.6%, normal lung function. Among individuals with obstructive lung function, 45.3%, 49.4%, and 5.3% had mild, moderate, and severe and very severe airflow limitation. The prevalence of hypertension, diabetes mellitus (DM), underweight, and hypertriglyceridemia was higher in the obstructive lung function group than in the normal lung function group (49.6% vs 35.2%; 16.8% vs 10.5%; 3.3% vs 1.3%; 19.7% vs 17.0%). According to the severity of airway obstruction, hypertension and underweight were more common as severity increased, although the prevalence of DM and hypertriglyceridemia was lower in subjects with severe airway obstruction. The prevalence of hypercholesterolemia, overweight, and osteoarthritis was lower in the obstructive lung function group, especially in the severe airway obstruction groups.

CONCLUSIONS

Overall, our analysis is similar to research that was conducted earlier. Our study showed that hypertension and underweight are common comorbidities in COPD patients, and are higher as the severity of airflow obstruction increased in both men and women. DM, hypertriglyceridemia, and low high-density lipoprotein cholesterol are more common in subjects with airway obstruction, although their incidence is lower in the severe group.

Screening for diabetes mellitus in patients with chronic obstructive pulmonary disease in tertiary care hospital in India

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) are common and under diagnosed medical conditions in India. Prevalence of these chronic diseases are high both in rural and urban areas. However, exact prevalence of DM in Indian COPD patients in unclear. Co-morbid conditions like DM have great impact on the outcome of COPD in the form of severity, exacerbations, morbidity and mortality. Hence the present study objective was to screen COPD patients for DM.

RESULTS

A total of 1662 patients with COPD (Males = 1264, Female = 398) with mean age 58 ± 9.6 were screened for DM. Patients with known history of DM were 353 (21.24%) and were enrolled as Known DM cases. Remaining 1309 (78.76%) patients whose DM status was unclear were screened by random blood sugar (RBS). One-hundred and seventy-one subjects had RBS > 110 mg/dl. About 73 (4.39%) subjects had fasting blood sugar (FBS) > 126 mg/dl. They were considered as Newly Diagnosed DM cases. Total number of DM cases in the study including new and known was 426 (25.63%). Number of patients with deranged FBS (FBS between 110 mg/dl to126 mg/dl) was 84 (5.05%). Among the DM patients with COPD 168 (10.11%) had poor glycemic control with HbA1c > 8. Prevalence of DM in present study was 25.63%.

CONCLUSION

Prevalence of DM in COPD patients in the present study is 25.63% when actively screened in tertiary care hospital. It is feasible and imperative to screen all COPD patients for DM in all health care facilities routinely.

Walking Pattern in COPD Patients

PURPOSE

To compare the activity and walking pattern of individuals with chronic obstructive pulmonary disease (COPD) and control subjects during a 24-hour period.

DESIGN

Cross-sectional study in home and community.

METHODS

The average walking velocity, time spent in sitting, standing, and lying, and numbers of steps per 24 hours were measured in nine individuals with COPD and eight healthy control subjects.

FINDINGS

The average walking velocity in individuals with COPD was equivalent to that of the control subjects. Individuals with COPD walked significantly less than the control subjects. The total time spent sitting, standing, and walking was similar in the two groups.

CONCLUSIONS

The results suggested that the walking velocity selected by individuals with COPD serves to minimize energy cost per distance.

CLINICAL RELEVANCE

The study findings emphasize the need to maintain walking velocity in any exercise prescription for individuals with COPD.

Comparison of global initiative for chronic obstructive pulmonary disease 2013 classification and body mass index, airflow obstruction, dyspnea, and exacerbations index in predicting mortality and exacerbations in elderly adults with chronic obstructive pulmonary disease

OBJECTIVES

To examine whether the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) 2013 revision offers greater predictive ability than the body mass index, airflow obstruction, dyspnea, and exacerbations (BODEx) index in elderly adults with chronic obstructive pulmonary disease (COPD).

DESIGN

Prospective cohort study.

SETTING

University-affiliated medical center.

PARTICIPANTS

Taiwanese outpatients with COPD (N = 354).

MEASUREMENTS

Participants were classified as Group A (low risk with mild dyspnea), Group B (low risk with more-severe dyspnea), Group C (high risk with mild dyspnea), and Group D (high risk with more-severe dyspnea) for GOLD 2013 and from Quartile 1 (0-2 points) to 4 (7-9 points) for BODEx score. Ability to predict exacerbations and mortality was compared using logistic regression analysis with receiver operating characteristic (ROC) curve estimations and area under the ROC curve (AUC).

RESULTS

Mortality was 14.1% for GOLD Group A, 14.5% for Group B, 6.5% for Group C, and 35.8% for Group D and 15.2% for BODEx Quartile 1, 22.5% for Quartile 2, 28.1% for Quartile 3, and 79.2% for Quartile 4. Risk of exacerbation relative to Group A was 1.7 (95% confidence interval (CI) = 0.6-4.3) for Group B, 14.1 (95% CI = 4.6-43.2) for Group C, and 17.9 (95% CI = 7.6-42.0) for Group D. The AUC for the GOLD classification and BODEx index were 0.65 and 0.67 for mortality (P = .60) and 0.79 and 0.73 for exacerbation (P = .03).

CONCLUSION

The GOLD 2013 classification performed well in identifying individuals at risk of exacerbations, and its predictive ability for exacerbations was better than that of the BODEx index, although the predictive ability for mortality in elderly adults with COPD was poor for both indices.

Detection of airflow limitation using a handheld spirometer in a primary care setting

Background and objective

Early diagnosis of chronic obstructive pulmonary disease (COPD) in primary care settings is difficult to achieve chiefly due to lack of availability of spirometry. This study estimated the prevalence of airflow limitation among chronic smokers using a handheld spirometer in this setting.

Methods

This is a cross-sectional study performed on consecutive patients who were ≥40 years old with ≥10 pack-years smoking history. Face-to-face interviews were carried out to obtain demographic data and relevant information. Handheld spirometry was performed according to a standard protocol using the COPd-6 device (Model 4000, Vitalograph, Ennis, Ireland) in addition to standard spirometry. Airflow limitation was defined as ratio of forced expiratory volume in 1 s (FEV₁)/forced expiratory volume in 6 s <0.75 (COPd-6) or FEV₁/forced vital capacity <0.7. Multiple logistic regression analyses were used to determine predictors of airflow limitation.

Results

A total of 416 patients were recruited with mean age of 53 years old. The prevalence of airflow limitation was 10.6% (n = 44) with COPd-6 versus 6% as gauged using standard spirometry. Risk factors for airflow limitation were age >65 years (odds ratio (OR) 3.732 95% confidence interval (CI): 1.100–1.280), a history of ‘bad health’ (OR 2.524, 95% CI: 1.037–6.142) and low to normal body mass index (OR 2.914, 95% CI: 1.191–7.190).

Conclusions

In a primary care setting, handheld spirometry (COPd-6) found a prevalence of airflow limitation of ∼10% in smokers. Patients were older, not overweight and had an ill-defined history of health problems.

SUMMARY AT A GLANCE

Prevalence of COPD is unknown in Malaysia. The prevalence of COPD using a handheld spirometer (COPd-6TM) was 10.6% versus 6% as gauged using standard spirometry. Predictors of COPD were older age, lower BMI and a history of ‘bad health’. Case-finding for COPD should be targeted in this special population.

Patterns and determinants of COPD-related healthcare utilization by severity of airway obstruction in Korea

Background

We investigated patients with chronic obstructive pulmonary disease (COPD) to analyze patterns and identify determinants of healthcare use, according to the severity of airflow obstruction. We used retrospective cohort data from a combination of the 4^th Korea National Health and Nutritional Examination Survey (KNHANES) and Korean National Health Insurance (NHI) claims.

Methods

Demographic and medical claims data were retrospectively analyzed from the 4^th KNHANES along with NHI claims. Eligible patients were aged ≥40 years, who underwent complete pulmonary function tests (PFTs), and had at least one inpatient or outpatient claim coded as COPD between January 1, 2007 and December 31, 2010.

Results

Among 6,663 eligible participants, 897 (13.5%) had airway obstruction. Self-reported physician-diagnosed COPD comprised only 3%, and there were 870 undiagnosed COPD patients (97%). Self-reported physician-diagnosed asthma made up 3.7%. Of the 897 respondents, 244 (27.2%) used COPD-related healthcare services. The frequency of healthcare visits increased with increasing severity of airway obstruction. After a 3-year follow-up period, 646 (74.2% of those initially undiagnosed) remained undiagnosed and only 224 (25.8%) were diagnosed and treated for COPD. Only 27.5% of the 244 participants with airway obstruction who used COPD-related healthcare underwent PFTs during the study period. The percentage of prescribed medications associated with COPD increased in accordance with the severity of the COPD. Inhaled long-acting anticholinergics were prescribed for 10.9% of patients with moderate airway obstruction and for 52.4% of patients with severe obstruction. Inhaled long-acting β-agonists combined with corticosteroids were prescribed for 50% of patients with severe airway obstruction. Conversely, 44.6% of healthcare users were prescribed oral theophylline for COPD treatment, and 21.7% were also prescribed an oral corticosteroid. The determinants of COPD-associated healthcare use in respondents with obstructive lung disease were advanced age, severe airflow limitation, presence of comorbidities, and self-reported physician diagnosis of COPD.

Conclusions

This study ascertained marked underdiagnosed COPD. Although the percentage of prescribed medication used to treat COPD increased with the severity of the COPD, medications primarily prescribed such as oral theophylline or oral corticosteroids are inappropriate for first-line COPD treatment.

Development and preliminary validation of a questionnaire on regular exercise beliefs among patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

To develop a Regular Exercise Belief Questionnaire and test its psychometric properties for patients with chronic obstructive pulmonary disease.

BACKGROUND

Regular exercise has been shown to significantly improve physical capacity and the quality of life of patients with chronic obstructive pulmonary disease. However, their adherence to long-term exercise is low. To develop an effective strategy for promoting good exercise behaviours, it is important to have a validated instrument to evaluate factors related to engaging in exercise.

DESIGN AND METHODS

A cross-sectional design was used for the study. Construction of the Regular Exercise Belief Questionnaire was based on the Theory of Planned Behaviour Reliability and validity were assessed using a sample of 136 male patients with chronic obstructive pulmonary disease. The construct validity of the questionnaire was confirmed through exploratory factor analysis and known group technique.

RESULTS

Exploratory factor analysis resulted in an eight-factor solution that explained 70·4% of the total variance. The internal consistency of the Regular Exercise Belief Questionnaire was 0·83-0·93. The Regular Exercise Belief Questionnaire was preliminarily found to be reliable and exhibited satisfactory validity for patients with chronic obstructive pulmonary disease.

CONCLUSION

The Regular Exercise Belief Questionnaire is the first theory-based measure of exercise beliefs among patients with chronic obstructive pulmonary disease. The questionnaire provides an effective method to examine behaviour beliefs, normative beliefs and control beliefs about regular exercise.

CLINICAL RELEVANCE

The measure can be used to periodically evaluate the exercise beliefs in clinics and to examine the effectiveness of exercise programmes in patients with chronic obstructive pulmonary disease. The result of the evaluation could also apply to identify strategies related to promoting exercise behaviours.

Association of Egr-1 and autophagy-related gene polymorphism in men with chronic obstructive pulmonary disease

BACKGROUND/PURPOSE

Autophagy is important in cellular homeostasis and control of inflammatory immune response. Increased autophagy has recently been associated with increased cell death and chronic obstructive pulmonary disease (COPD) pathogenesis. Two autophagy regulator genes have been identified: Egr-1 (early growth response), associated with different phenotype expressions in asthma; and, Atg16L1 (autophagy related 16-like 1), a candidate gene responsible for susceptibility to chronic inflammatory diseases. We will explore the role of the Egr-1 and Atg16L1 gene polymorphisms in COPD.

METHODS

The genotypes of 151 male smoking patients with COPD and 100 male smoking controls were evaluated by polymerase chain reaction followed by restriction fragment length polymorphism analysis of the Egr-1 (-4071 A → G) rs7729723 and Atg16L-1 (T300A) rs2241880 variants.

RESULTS

The G allele of the Egr-1 gene polymorphism was associated with an increased risk of developing COPD [odds ratio (OR), 2.05; 95% confidence interval (CI), 1.15-3.72], and participants with the G allele polymorphism (GG and GA genotypes) had a 2.56-fold higher risk (OR, 2.56; 95% CI, 1.31-5.16) of having COPD than those homozygous for the A allele [35.8% (54/151) vs. 24.0% (24/100); p = 0.007]. Participants with the A allele of the Atg16L1 gene polymorphism (AA and AG genotypes) had a 3.34-fold higher risk (OR, 3.34; 95% CI, 1.32-8.97) of having COPD than those homozygous for the G allele [93.4% (141/151) vs. 81.0% (81/100); p = 0.013].

CONCLUSION

The Egr-1 and Atg16L1 genes' polymorphisms were significant risk factors for susceptibility to COPD. These results demonstrate that autophagy regulator genetic mutations are associated with COPD in male smokers.

Antibiotics for treatment and prevention of exacerbations of chronic obstructive pulmonary disease

Acute exacerbations (AE) can be recurrent problems for patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) increasing morbidity and mortality. Evidence suggests that ≥50% of acute exacerbations involve bacteria requiring treatment with an antibiotic which should have high activity against the causative pathogens. However, sputum analysis is not a pre-requisite for antibiotic prescription in outpatients as results are delayed and patients are likely to be colonised with bacteria in the stable state. Clinicians rely on the clinical symptoms, sputum appearance and the patient's medical history to decide if an AE-COPD should be treated with antibiotics. This article reviews the available data of antibiotic trials in AE-COPD. Management of frequent exacerbators is particularly challenging for physicians. This may include antibiotic prophylaxis, especially macrolides because of anti-inflammatory properties; though successful in reducing exacerbations, concerns about resistance development remain. Inhalation of antibiotics achieves high local concentrations and minimal systemic exposure; therefore, it may represent an attractive alternative for antibiotic prophylaxis in certain COPD patients. Inhaled antibiotic prophylaxis has been successfully used in other respiratory conditions such as non-cystic fibrosis bronchiectasis which itself might be present in COPD patients who have chronic bacterial infection, particularly with Pseudomonas aeruginosa.

Comorbidities of chronic obstructive pulmonary disease in Koreans: a population-based study

Chronic obstructive pulmonary disease (COPD) includes pulmonary components with increased comorbidity rates, as well as being a systemic disease. Comorbidities may frequently occur in COPD patients over 40 yr old. We report the comorbidities of patients with COPD, diagnosed by spirometry, in a population-based epidemiologic survey in Korea. Data were derived from the fourth Korean Health and Nutrition Examination Survey in 2008, a stratified multistage clustered probability design survey of a sample representing the entire population of Korea. Results of spirometry and various health-related questionnaires were analyzed in 2,177 subjects aged ≥ 40 yr. The prevalence of COPD (FEV(1)/FVC < 0.7) in subjects ≥ 40 yr of age was 14.1%. Multivariate analysis showed that underweight (odds ratio [OR] 3.07, 95% confidence interval [CI] 1.05-8.98), coronary heart disease (OR, 0.43; 95% CI, 0.20-0.93) and dyslipidemia (OR, 0.61; 95% CI, 0.45-0.82) were significantly associated with COPD, whereas allergic rhinitis, anemia, arthritis, chronic renal failure, depression, diabetes mellitus, hypertension, gastrointestinal ulcer, and osteoporosis were not. Underweight might be more prevalent but coronary heart disease and dyslipidemia are less prevalent in Koreans with than without COPD in population setting.

The use of age-period-cohort analysis to determine the impact of economic development on COPD mortality in Hong Kong

Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide. The rising trend in COPD-related mortality can be linked to aging populations and trends in risk factors possibly correlated with macroeconomic development. An age-period-cohort analysis of data on a recently developed economy, Hong Kong, is able to decompose sex-specific COPD mortality rates into age, period and birth-cohort effects to examine the possible impacts of defined macro-level events. The findings of this study corroborate the relationship between COPD incidence and an aging population, shows strong evidence for declining COPD mortality among generations raised in a more economically developed environment, but, possibly due to modeling limitations, only mixed results regarding the impact of changes in air quality.

The role of bactericidal/permeability-increasing protein in men with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

Bactericidal/permeability-increasing protein (BPI) is a member of the pattern recognition receptors of the innate immune system. Recently, an association between genetic polymorphism in the BPI gene and a risk of airflow decline after transplantation was demonstrated, but whether these findings are reproducible in nontransplantation populations, such as those with COPD, is still unknown. The aim of this study is to explore the role of BPI in COPD.

METHODS

The genotypes of 107 patients with COPD and 110 control subjects were evaluated by polymerase chain reaction and polymorphism analysis of the BPI genes and ELISA analysis of the plasma BPI level. All subjects were men over 40 years old who smoked.

RESULTS

BPI mutation PstI (T→C) polymorphism in intron 5 was associated with an increased risk of developing COPD (OR 3.73, 95%CI: 1.62-9.10), and the frequency was significantly increased in the COPD group compared with the control group (26/107 [24.3%] vs 12/110 [10.9%], p = 0.002). In addition, COPD patients exhibited a decreased plasma level of BPI compared with the control group (10.6 ± 2.2 vs 23.4 ± 2.1 ng/ml, p < 0.0001).

CONCLUSIONS

BPI mutation (PstI in intron 5) and a decreased plasma BPI level were significant risk factors in susceptibility to COPD. These results demonstrate that BPI genetic mutation and impaired BPI production or release may result in airflow obstruction in smokers.

Economic burden of chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

The aim of this study was to estimate the direct medical costs of COPD in two public health clusters in Singapore from 2005 to 2009.

METHODS

Patients aged 40 years and over, who had been diagnosed with COPD, were identified in a Chronic Disease Management Data-mart. Annual utilization of health services in inpatient, specialist outpatient, emergency department and primary care settings was extracted from the Chronic Disease Management Data-mart. Trends in attributable costs, proportions of costs and health-care utilization were analyzed across each level of care. A weighted attribution approach was used to allocate costs to each health-care utilization episode, depending on the relevance of co-morbidities.

RESULTS

The mean total cost was approximately $9.9 million per year. Inpatient admissions were the major cost driver, contributing an average of $7.2 million per year. The proportion of hospitalization costs declined from 75% in 2005 to 68% in 2009. Based on the 5-year average, attendances at primary care clinics, emergency department and specialist clinics contributed 3%, 5% and 17%, respectively, of overall COPD costs. On average, 42% of the total cost burden was incurred for the medical management of COPD. The share of cost incurred for the treatment of conditions related and unrelated to COPD were 29% and 26%, respectively, of the total average costs.

CONCLUSIONS

COPD is likely to represent a significant burden to the public health system in most countries. The findings are particularly relevant to understanding the allocation of health-care resources and informing appropriate cost containment strategies.

Roflumilast in Asian patients with COPD: A randomized placebo-controlled trial

BACKGROUND AND OBJECTIVE

Roflumilast, an oral, selective phosphodiesterase 4 inhibitor, has been shown to reduce exacerbations and improve pulmonary function in patients with COPD. This study examined the efficacy, safety and tolerability of roflumilast in Asian patients with COPD.

METHODS

Patients with COPD were randomized 1:1 to enter a 12-week treatment period and receive either oral roflumilast, 500 µg once daily, or placebo, following a single-blind, 4-week baseline period in which all patients received placebo. The primary end point was mean change in FEV₁ from baseline to each postrandomization visit during the treatment period. Other spirometric lung function measurements were evaluated as secondary end points. COPD exacerbations were monitored. Safety was assessed from clinical laboratory tests, vital signs, physical examination (including electrocardiogram) and monitoring of adverse events (AEs).

RESULTS

Of 551 patients recruited, 410 were randomized and received at least one dose of study medication (roflumilast, n = 203; placebo, n = 207). Superiority of roflumilast over placebo was demonstrated by a statistically significant difference in postbronchodilator FEV₁ (79 mL, P < 0.0001). Other spirometry end points, including prebronchodilator FEV₁, pre-and postbronchodilator FEV₆, forced vital capacity and peak expiratory flow significantly favoured roflumilast over placebo. AEs were more common with roflumilast than with placebo, but were comparable with those reported in previous studies.

CONCLUSIONS

Roflumilast, 500 µg once daily, improves pulmonary function in Asian patients with COPD. The safety and tolerability of roflumilast in this population was similar to that in a Caucasian population.