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Gessner C, Trinkmann F, Bahari Javan S, Hövelmann R, Bogoevska V, Georges G, Nudo E, Criée CP. Effectiveness of Extrafine Single Inhaler Triple Therapy in Chronic Obstructive Pulmonary Disease (COPD) in Germany - The TriOptimize Study. Int J Chron Obstruct Pulmon Dis 2022; 17:3019-3031. [PMID: 36483674 PMCID: PMC9725928 DOI: 10.2147/copd.s382405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/24/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose Real-word evidence on the effectiveness of switching from dual therapies or triple therapies (multiple inhalers) to extrafine single-inhaler triple therapy (efSITT), which consists of the inhaled corticosteroid (ICS) beclomethasone, the long-acting β2-agonist (LABA) formoterol and the long-acting muscarinic antagonist (LAMA) glycopyrronium, in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) is limited. The impact of switching to efSITT on health-related quality of life (HRQoL), COPD specific symptoms, lung function and treatment adherence were assessed in routine clinical care. Patients and Methods Patients were recruited at 148 sites in Germany between 2017 and 2020 in this multicenter, non-interventional observational study. Demographics, clinical data and treatment history were collected at baseline. HRQoL (measured by COPD Assessment Test [CAT]), lung function and adherence (measured by Test of Adherence to Inhalers [TAI]) were assessed at baseline and after six months. Descriptive analyses were conducted by prior treatment and GOLD groups as well as for the overall population. Results 55.1% of the 2623 included patients were male. Mean age was 65.8 years. 57.5% of the patients were previously treated with ICS+LABA+LAMA (multiple inhalers), 23.9% with ICS/LABA (single or two inhalers) and 18.6% with LAMA/LABA (single or two inhalers). After six months, largest mean improvements in the total CAT score were observed in the ICS/LABA (-3.9) and LAMA/LABA (-3.9) prior treatment groups as well as in patients in GOLD group B (-2.9). In the overall population, the CAT items for cough, phlegm, and dyspnea decreased on average by -0.4 points each. After six months, FEV1 increased by 2.0 percentage points in relation to predicted values. The percentages of measured sRtot and RV of predicted values decreased by 24.5 and 4.4 percentage points, respectively. The percentage of patients with good adherence increased from 67.8% to 76.5%. Conclusion Treatment switch to efSITT resulted in an improvement of HRQoL, COPD specific symptoms, lung function parameters and adherence under real-world conditions.
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Affiliation(s)
- Christian Gessner
- Pneumologische Praxis Leipzig, Universitätsklinikum Leipzig, Institut für Klinische Immunologie, Leipzig, Germany,Correspondence: Christian Gessner, Pneumologische Praxis Leipzig, Universitätsklinikum Leipzig, Institut für Klinische Immunologie, Tauchaer Straße 12, Leipzig, 04357, Germany, Tel +49 341 60 20 960, Email
| | - Frederik Trinkmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University Hospital Heidelberg, Translational Lung Research Center Heidelberg (TLRC), Member of German Center for Lung Research (DZL), Heidelberg, Germany,Department of Biomedical Informatics (DBMI) at the Center for Preventive Medicine and Digital Health Baden-Württemberg (CPD-BW), University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | | | | | | | | | - Elena Nudo
- Global Medical Affairs, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - Carl-Peter Criée
- Department of Sleep and Respiratory Medicine, Evangelical Hospital Goettingen-Weende, Bovenden, Germany
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2
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Rana RH, Alam K, Keramat SA, Gow J. Cost-effectiveness of single-inhaler triple therapy for patients with severe COPD: A systematic literature review. Expert Rev Respir Med 2022; 16:1067-1084. [DOI: 10.1080/17476348.2022.2145951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rezwanul Hasan Rana
- Centre for the Health Economy, Macquarie University, Macquarie Park, Australia
- Australian Institute of Health and Innovation, Macquarie University, Macquarie Park, Australia
| | - Khorshed Alam
- University of Southern Queensland, Toowoomba, Australia
| | | | - Jeff Gow
- University of Southern Queensland, Toowoomba, Australia
- School of Accounting, Economics and Finance, University of KwaZulu-Natal, Durban, South Africa
- Department of Agricultural Economics, Stellenbosch University, Stellenbosch, South Africa
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3
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Resta E, Scioscia G, Lacedonia D, Quarato CMI, Panza F, Resta O, Lepore G, Buonamico E, Di Lecce V, Carpagnano GE, Barbaro MPF, Rossi N. Economic impact of implementing prescription of single-inhaler triple therapies versus current multiple-inhaler triple therapies for COPD in the Apulia Region. BMC Health Serv Res 2022; 22:1283. [PMID: 36284319 PMCID: PMC9595082 DOI: 10.1186/s12913-022-08640-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The most impacting direct costs associated to COPD for the National Health Systems (NHS) are those related to accesses to the emergency room and hospital admissions, due to the onset of one or more COPD exacerbations. At the same time, severe COPD treatment, that often require a combination of medicaments, represents a substantial economic burden for the National Health Systems (NHS). This study aimed to evaluate the potential saving deriving from the implementation in the prescription of the two currently available single-inhaler triple therapies (SITTs) versus the currently used multiple-inhaler triple therapies (MITTs) in an eligible COPD population residing in the Apulia Region. METHODS A budget impact model was developed hypothesizing the progressive replacement of the different MITTs on the reference market (Scenario A) with the pre-established SITTs, assuming a degree of penetration of 30%, 50% and 100% (Scenario B). Drug costs were based on prices published on the Official Gazette and therapy durations were based on prescribing information over the year 2019 (IQVIA™ prescription dataset). RESULTS Our analysis showed that the extemporaneous MITT with the highest prevalence on the reference market was the inhaled corticosteroids/long-acting β2-agonists (ICS/LABA) combination plus a long-acting muscarinic antagonists (LAMA). This association of medicaments was paradoxically also the one associated to the highest expense value. The expanded use of a pre-established ICS/LAMA/LABA SITT was associated to a significant economic saving, ranging from a minimum of -€ 1,108,814 (SITT use: 30%) to a maximum of -€ 3,658,950 (SITT use: 100%). The cheapest pre-established SITT contained the fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) combination. CONCLUSION A pre-fixed ICS/LAMA/LABA SITT is cost-saving, compared to the different currently used extemporaneous MITTs. Clinicians should consider the potential benefits of finding less expensive regimens while maintaining adequate efficacy in the prescriptive decision making process of COPD patients.
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Affiliation(s)
- Emanuela Resta
- grid.10796.390000000121049995Translational Medicine and Health System Management, Department of Economy, University of Foggia, Foggia, Italy
| | - Giulia Scioscia
- grid.10796.390000000121049995Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, Policlinico Universitario “Riuniti” di Foggia, University of Foggia, Foggia, Italy
| | - Donato Lacedonia
- grid.10796.390000000121049995Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, Policlinico Universitario “Riuniti” di Foggia, University of Foggia, Foggia, Italy
| | - Carla Maria Irene Quarato
- grid.10796.390000000121049995Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, Policlinico Universitario “Riuniti” di Foggia, University of Foggia, Foggia, Italy
| | - Francesco Panza
- Population Health Unit, “Salus in Apulia Study”, Research Hospital, National Institute of Gastroenterology “Saverio de Bellis”, Castellana Grotte, Bari, Italy
| | - Onofrio Resta
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University “Aldo Moro” of Bari, Bari, Italy
| | - Giorgia Lepore
- grid.10796.390000000121049995Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, Policlinico Universitario “Riuniti” di Foggia, University of Foggia, Foggia, Italy
| | - Enrico Buonamico
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University “Aldo Moro” of Bari, Bari, Italy
| | - Valentina Di Lecce
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University “Aldo Moro” of Bari, Bari, Italy
| | - Giovanna Elisiana Carpagnano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University “Aldo Moro” of Bari, Bari, Italy
| | - Maria Pia Foschino Barbaro
- grid.10796.390000000121049995Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, Policlinico Universitario “Riuniti” di Foggia, University of Foggia, Foggia, Italy
| | - Noemi Rossi
- grid.11567.340000000122070761Department of Law, Economics and Human Sciences (DIGIES) “Mediterranea”, University of Reggio Calabria, Reggio Calabria, Italy
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4
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Zhang L, Wang X, Zhang Y, Chen W. Efficacy and Safety of Single Inhaler Triple Therapy Versus Separate Triple Therapy in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis. Clin Ther 2022; 44:859-873. [DOI: 10.1016/j.clinthera.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/03/2022] [Accepted: 04/08/2022] [Indexed: 11/16/2022]
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Braido F, Corsico AG, Paleari D, Piraino A, Cavalieri L, Scichilone N. Why small particle fixed dose triple therapy? An excursus from COPD pathology to pharmacological treatment evolution. Ther Adv Respir Dis 2022; 16:17534666211066063. [PMID: 35044875 PMCID: PMC8796083 DOI: 10.1177/17534666211066063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022] Open
Abstract
Although bronchodilators are the cornerstone in chronic obstructive pulmonary disease (COPD) therapy, the treatment with a single-agent bronchodilator may not provide adequate symptoms control in COPD. The combination of drugs with different mechanisms of action may be more effective in inducing bronchodilation and preventing exacerbations, with a lower risk of side-effects in comparison with the increase of the dose of a single molecule. Several studies comparing the triple therapy with the association of long-acting ß2 agonist (LABA)/inhaled corticosteroid (ICS) or long-acting muscarinic antagonist (LAMA)/LABA reported improvement of lung function and quality of life. A significant reduction in moderate/severe exacerbations has been observed with a fixed triple combination of beclometasone dipropionate (BDP), formoterol fumarate (FF) and glycopyrronium (G) in a single inhaler. The TRILOGY, TRINITY and TRIBUTE studies have provided confirming evidence for a clinical benefit of triple therapy over ICS/LABA combination treatment, LAMA monotherapy and LABA/LAMA combination, with prevention of exacerbations being a key finding. A pooled post hoc analysis of the published clinical studies involving BDP/FF/G fixed combination demonstrated a reduction in fatal events in patients treated with ICS-containing medications, with a trend of statistical significance [hazard ratio = 0.72, 95% confidence interval (CI) 0.50-1.02, p = 0.066], that becomes significant if we consider reduction in fatal events for non-respiratory reasons (hazard ratio = 0.65, 95% CI 0.43-0.97, p = 0.037). In conclusion, a fixed combination of more drugs in a single inhaler can improve long-term adherence to the therapy, reducing the risk of exacerbations and hospital resources utilization. The twice a day administration may provide a better coverage of night, particularly in COPD patients who are highly symptomatic. The inhaled extrafine formulation that allows drug deposition in both large and small - peripheral - airways, is the value added.
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Affiliation(s)
- Fulvio Braido
- Associate Professor of Respiratory Medicine University of Genoa Head of Respiratory Unit for continuity of care IRCCS Ospedale Policlinico San Martino - Genova
| | - Angelo G. Corsico
- Division of Respiratory Diseases, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia 27100, Italy
| | - Davide Paleari
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
| | - Alessio Piraino
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
| | - Luca Cavalieri
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
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Usmani OS, Dhand R, Lavorini F, Price D. Why We Should Target Small Airways Disease in Our Management of Chronic Obstructive Pulmonary Disease. Mayo Clin Proc 2021; 96:2448-2463. [PMID: 34183115 DOI: 10.1016/j.mayocp.2021.03.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/12/2021] [Accepted: 03/16/2021] [Indexed: 12/23/2022]
Abstract
For more than 50 years, small airways disease has been considered a key feature of chronic obstructive pulmonary disease (COPD) and a major cause of airway obstruction. Both preventable and treatable, small airways disease has important clinical consequences if left unchecked. Small airways disease is associated with poor spirometry results, increased lung hyperinflation, and poor health status, making the small airways an important treatment target in COPD. The early detection of small airways disease remains the key barrier; if detected early, treatments designed to target small airways may help reduce symptoms and allow patients to maintain their activities. Studies are needed to evaluate the possible role of new drugs and novel drug formulations, inhalers, and inhalation devices for treating small airways disease. These developments will help to improve our management of small airways disease in patients with COPD.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute, Imperial College London, and Royal Brompton Hospital, Airways Disease Section, London, UK.
| | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - David Price
- Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, Cambridge, UK; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Lee HW, Kim HJ, Jang EJ, Lee CH. Comparisons of Efficacy and Safety between Triple (Inhaled Corticosteroid/Long-Acting Muscarinic Antagonist/Long-Acting Beta-Agonist) Therapies in Chronic Obstructive Pulmonary Disease: Systematic Review and Bayesian Network Meta-Analysis. Respiration 2021; 100:631-643. [PMID: 33971649 DOI: 10.1159/000515133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Various combinations of inhaled corticosteroid (ICS), long-acting muscarinic antagonist (LAMA), and long-acting beta-agonist (LABA) have been used as triple therapy for stable chronic obstructive pulmonary disease (COPD). OBJECTIVE Our study was conducted to answer whether there were significant differences among various combinations in efficacy, for reducing exacerbation or mortality, and in safety, for increasing cardiovascular events or pneumonia. METHOD We searched parallel-group randomized controlled trials (RCTs) comparing ICS/LAMA/LABA with other inhaled drugs in patients with stable COPD for at least 12 weeks in PubMed, EMBASE, the Cochrane Library, and clinical trial registries from inception to December 31, 2019. We conducted a network meta-analysis with Bayesian statistics using a random-effects model with heterogeneous variance structure (PROSPERO, CRD42019126757). RESULTS Nine different combinations of ICS/LAMA/LABA were identified in 21 RCTs containing 29,892 patients with moderate to very severe COPD. We could not find any significant evidence suggesting a better treatment for reducing total exacerbations or all-cause mortality among ICS/LAMA/LABA combinations. There were also no significant differences in moderate to severe exacerbation, COPD-related mortality, or cardiovascular disease-related mortality among ICS/LAMA/LABA combinations, and the risk of major adverse cardiovascular events was not different. A significantly lower risk of pneumonia was found in fluticasone propionate (FP)/glycopyrrolate/salmeterol (SAL) than FP/tiotropium/SAL {median odds ratio [OR] (95% credible interval [CrI]) = 0 [0-0.72]} and FP/umeclidinium/SAL {median OR (95% Crl) = 0 [0-0.97]}. CONCLUSION There were no significant differences in clinical outcomes, including acute exacerbation and all-cause mortality among various ICS/LAMA/LABA combinations in patients with moderate to very severe COPD.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Dongjak-gu, Seoul, Republic of Korea
| | - Hyung Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Jongno-Gu, Seoul, Republic of Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Jongno-Gu, Seoul, Republic of Korea
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Sansbury LB, Bains C, Lipson DA, Ismaila AS, Landis SH. Real-World Treatment Patterns of Multiple-Inhaler Triple Therapy Among Patients with Chronic Obstructive Pulmonary Disease in UK General Practice. Int J Chron Obstruct Pulmon Dis 2021; 16:1255-1264. [PMID: 33986594 PMCID: PMC8110279 DOI: 10.2147/copd.s290773] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/29/2021] [Indexed: 01/10/2023] Open
Abstract
Introduction Until recently, triple therapy for chronic obstructive pulmonary disease (COPD) has only been available through treatment with multiple inhalers. Evidence on real-world use of multiple-inhaler triple therapy (MITT), including duration of use and treatment patterns, is limited. Methods A retrospective, observational study of electronic health records and hospital episodes in patients with COPD initiating MITT between 2013 and 2015 in the UK was performed. This study described patients initiating, treatment persistence and discontinuation, and prior and subsequent COPD treatments. Results Eligible patients (N=3825) had a mean age of 69.5 years; most were former or current smokers (95%). The majority (86%) initiated MITT with two inhalers and 14% initiated with three inhalers. Mean duration of use was 5.1 (standard deviation: 4.6) months; 24% of patients persisted for 12 months. Patients who had significantly poorer lung function at baseline (12 months prior to initiating MITT) and had experienced significantly more moderate-to-severe acute exacerbation of COPD (AECOPD) and hospitalizations during the baseline period were more likely to persist for 12 months, compared with those who discontinued within 12 months. Most patients stepped down to an inhaled corticosteroid/long-acting β2-agonist combination (ICS/LABA; 48%) or a long-acting muscarinic antagonist (LAMA; 45%) after discontinuing MITT. Conclusion Initiation of MITT occurred in patients with clinically relevant symptoms and a history of AECOPD. Persistence varied and was most likely linked to disease severity, although more research is required to fully understand why patients discontinue MITT, the subsequent clinical consequences of therapy discontinuation, and the potential impact of newly available single-inhaler triple therapies.
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Affiliation(s)
- Leah B Sansbury
- Value Evidence and Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Chanchal Bains
- Value Evidence and Outcomes, GlaxoSmithKline, Uxbridge, UK
| | - David A Lipson
- Clinical Sciences, GlaxoSmithKline, Collegeville, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Afisi S Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sarah H Landis
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA
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Sicras-Mainar A, de Abajo FJ, Izquierdo-Alonso JL. Clinical and Economic Consequences of Inhaled Corticosteroid Doses and Particle Size in Triple Inhalation Therapy for COPD: Real-Life Study. Int J Chron Obstruct Pulmon Dis 2020; 15:3291-3302. [PMID: 33328730 PMCID: PMC7734046 DOI: 10.2147/copd.s281333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022] Open
Abstract
Objective To determine the clinical and economic consequences of inhaled corticosteroid doses and particle size in patients on triple-inhalation therapy for COPD. Methods Patients aged ≥40 years who initiated treatment with multi-inhaler triple-inhaled therapy between 1 January 2015 and 31 March were included and followed for 1 year. Patients were grouped according to inhaled corticosteroid (ICS) dose (low/medium/high) and particle size device (extrafine/non-extrafine particles). Outcome variables were moderate and severe exacerbations, pneumonia and healthcare resource use (HCRU) costs. A multivariate analysis was performed for model correction (p<0.05). Results A total of 2185 patients (mean age 72.3 years, 82.9% male) were analysed. Of these, 849 (38.9%) patients received low-dose ICS, 612 medium-dose ICS (28.0%) and 724 (33.1%) high-dose ICS. Exacerbations occurred more frequently with increasing IC dose (low: 26.4%, medium: 28.7% and high: 30.4%; p=0.047), as did the proportion of pneumonia (3.4%, 4.2% and 6.9%, respectively (p=0.041)). The annual mean cost/unit was € 2383 for low dose, € 2401 for medium dose and € 2625 for high dose (p=0.024). Four hundred and sixty-two (31.6%) patients used an extrafine particle device and 999 (68.4%) a non-extrafine particle device: the proportion of exacerbations was 24.0% vs 30.4% (p=0.012), and the annual mean cost/unit was € 2090 vs € 2513, respectively (p<0.001). The number of exacerbations was directly correlated with FEV1 (β= −0.157), age (β=0.071), Charlson index (β=0.050) and device type (extrafine: β=0.049) (p<0.02). Conclusion In patients with COPD receiving multi-inhaler triple therapy, higher ICS doses were not associated with a further reduction in exacerbations, whereas we found an increased risk of pneumonia. The use of inhaler devices delivering extrafine ICS particle was associated with a lower rate of exacerbations, resulting in lower overall HCRU costs.
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Affiliation(s)
| | - Francisco J de Abajo
- Unidad de Farmacología Clínica, Hospital Universitario Príncipe de Asturias, Madrid, Spain.,Departamento de Ciencias Biomédicas, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - José Luis Izquierdo-Alonso
- Departamento de Medicina y Especialidades, Universidad de Alcalá, Madrid, Spain.,Servicio de Neumología, Hospital Universitario de Guadalajara, Guadalajara, Spain
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Dean J, Panainte C, Khan N, Singh D. The TRIFLOW study: a randomised, cross-over study evaluating the effects of extrafine beclometasone/formoterol/glycopyrronium on gas trapping in COPD. Respir Res 2020; 21:323. [PMID: 33298062 PMCID: PMC7727250 DOI: 10.1186/s12931-020-01589-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 11/29/2020] [Indexed: 12/26/2022] Open
Abstract
Background The effects of triple therapy on gas trapping in COPD are not fully understood. We evaluated the effects of the long acting bronchodilator components of the extrafine single inhaler triple therapy beclometasone dipropionate/formoterol/glycopyrronium (BDP/F/G) pMDI on gas trapping. Methods This open-label, randomised, single centre, 2-way cross-over study recruited 23 COPD patients taking inhaled corticosteroid combination treatments and with residual volume (RV) > 120% predicted at screening. Inhaled BDP was taken during run-in and washout periods. Baseline lung function (spirometry, lung volumes, oscillometry) was measured over 12 h prior to randomisation to BDP/F/G or BDP/F for 5 days followed by washout and crossover. Lung function was measured prior to dosing on day 1 and for 12 h post-dose on day 5. Results Co-primary endpoint analysis: BDP/F/G had a greater effect than BDP/F on FEV1 area under the curve over 12 h (AUC0–12) (mean difference 104 mls, p = 0.0071) and RV AUC0–12 (mean difference − 163 mls, p = 0.0028). Oscillometry measurements showed a greater effect of BDP/F/G on the difference between resistance at 5 and 20 Hz (R5–R20) AUC0–12, which measures small airway resistance (mean difference − 0.045 kPa/L/s, p = 0.0002). Comparison of BDP/F with the baseline measurements (BDP alone) showed that F increased FEV1 AUC0–12 (mean difference 227 mls) and improved RV AUC0–12 (mean difference − 558 mls) and R5–R20 AUC0–12 (mean difference − 0.117 kPa/L/s), all p < 0.0001. Conclusions In COPD patients with hyperinflation, the G and F components of extrafine BDP/F/G improved FEV1, RV and small airway function. These long acting bronchodilators target small airway function, thereby improving gas trapping and airflow. Trial registration The study was retrospectively registered at ClinicalTrials.gov on 15th February 2019 (No.: NCT03842904, https://clinicaltrials.gov/ct2/show/NCT03842904).
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Affiliation(s)
- James Dean
- Medicines Evaluation Unit, Southmoor Road, Manchester, M23 9QZ, UK.
| | | | - Naimat Khan
- Medicines Evaluation Unit, Southmoor Road, Manchester, M23 9QZ, UK
| | - Dave Singh
- Medicines Evaluation Unit, Southmoor Road, Manchester, M23 9QZ, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
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11
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Usmani OS, Scichilone N, Mignot B, Belmans D, Van Holsbeke C, De Backer J, De Maria R, Cuoghi E, Topole E, Georges G. Airway Deposition of Extrafine Inhaled Triple Therapy in Patients with COPD: A Model Approach Based on Functional Respiratory Imaging Computer Simulations. Int J Chron Obstruct Pulmon Dis 2020; 15:2433-2440. [PMID: 33116458 PMCID: PMC7548261 DOI: 10.2147/copd.s269001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction There is a clear correlation between small airways dysfunction and poor clinical outcomes in patients with chronic obstructive pulmonary disease (COPD), and it is therefore important that inhalation therapy (both bronchodilator and anti-inflammatory) can deposit in the small airways. Two single-inhaler triple therapy (SITT) combinations are currently approved for the maintenance treatment of COPD: extrafine formulation beclomethasone dipropionate/formoterol fumarate/glycopyrronium bromide (BDP/FF/GB), and non-extrafine formulation fluticasone furoate/vilanterol/umeclidinium (FluF/VI/UMEC). This study evaluated the lung deposition of the inhaled corticosteroid (ICS), long-acting β2-agonist (LABA), and long-acting muscarinic antagonist (LAMA) components of these two SITTs. Materials and Methods Lung deposition was estimated in-silico using functional respiratory imaging, a validated technique that uses aerosol delivery performance profiles, patients’ high-resolution computed tomography (HRCT) lung scans, and patient-derived inhalation profiles to simulate aerosol lung deposition. Results HRCT scan data from 20 patients with COPD were included in these analyses, who had post-bronchodilator forced expiratory volume in 1 second (FEV1) ranging from 19.3% to 66.0% predicted. For intrathoracic deposition (as a percentage of the emitted dose), deposition of the ICS component was higher from BDP/FF/GB than FluF/VI/UMEC; the two triple therapies had similar performance for both the LABA component and the LAMA component. Peripheral deposition of all three components was higher with BDP/FF/GB than FluF/VI/UMEC. Furthermore, the ratios of central to peripheral deposition for all three components of BDP/FF/GB were <1, indicating greater peripheral than central deposition (0.48±0.13, 0.48±0.13 and 0.49±0.13 for BDP, FF and GB, respectively; 1.96±0.84, 0.97±0.34 and 1.20±0.48 for FluF, VI and UMEC, respectively). Conclusions Peripheral (small airways) deposition of all three components (ICS, LABA, and LAMA) was higher from BDP/FF/GB than from FluF/VI/UMEC, based on profiles from patients with moderate to very severe COPD. This is consistent with the extrafine formulation of BDP/FF/GB.
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Affiliation(s)
- Omar S Usmani
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Nicola Scichilone
- PROMISE Department of Medicine, University of Palermo, Palermo, Italy
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12
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López-Campos JL, Alcázar Navarrete B, Riesco Miranda JA, Cosío BG, de-Torres JP, Celli B, Jiménez-Ruiz CA, Casanova Macario C. A Delphi Consensus Document on the Use of Single-Inhaler Fixed-Dose Triple Therapies in COPD Patients. Int J Chron Obstruct Pulmon Dis 2020; 15:1801-1811. [PMID: 32884252 PMCID: PMC7435744 DOI: 10.2147/copd.s258818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/02/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction Despite the evidence provided by clinical trials, there are some uncertainties and controversies regarding the use of triple inhaled therapy. With the aim of evaluating clinical practice in specialized respiratory units, a Delphi consensus document was implemented on the use of single-inhaler fixed-dose triple therapies after 1 year of use in Spain. Methods A scientific committee of COPD experts defined a thematic index, guided a systematic literature review and helped design the Delphi questionnaire. This was sent to the other 45 COPD experts between April and June 2019. Agreement/disagreement on 58 statements was tested in two rounds using a Likert scale. Replies were classified as a consensus when ≥80% of the panelists agreed; a majority when a degree of agreement of ≥66% was reached; and divergence if agreement was <66%. Results After two rounds, 44.44% of the statements reached consensus, 14.81% reached majority and 40.74% were divergent. Panelists agreed that escalating from double bronchodilation should be phenotype-based and aim to prevent exacerbations but not for improving symptoms. The addition of an antimuscarinic to inhaled corticosteroids combinations achieves improvement in lung function, symptoms and exacerbation prevention. Main safety concerns included the increased risk of pneumonia as compared to bronchodilator therapies, with similar cardiovascular effects. There was no consensus agreement on patient type response based on blood eosinophil counts or obstruction severity. Conclusion The low degree of consensus among panelists may reflect the complexity of severe COPD management. The information provided here may be useful to clinicians implementing personalized medicine for COPD patients.
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Affiliation(s)
- José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Juan Antonio Riesco Miranda
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario de Cáceres, Cáceres, Spain
| | - Borja G Cosío
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Spain
| | | | - Bartolomé Celli
- Brigham and Women's Hospital, Harvard Medical School Boston, Boston, MA, USA
| | | | - Ciro Casanova Macario
- Servicio de Neumología-Unidad de Investigación, Hospital Universitario La Candelaria, Universidad de La Laguna, La Laguna, Spain
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13
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Salvi S, Deb AK, Agarwal M, Tummuru VR, Kodgule R, Hemalatha VS, Awasthi AK, Suraj KP, Pavitran VK, Mourya SP, Thomas P, Vaidya A, Chhowala S, Gogtay J. Fixed-dose combination of three drugs, i.e. LABA/LAMA/ICS for COPD: Results of a real-world study from India. Pulm Pharmacol Ther 2020; 63:101932. [PMID: 32777289 DOI: 10.1016/j.pupt.2020.101932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 06/17/2020] [Accepted: 07/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of triple therapy with inhaled corticosteroids, long-acting beta-agonist and long-acting antimuscarinics has been shown to be beneficial in COPD patients who continue to have symptoms and exacerbations, despite receiving dual bronchodilator combinations. This study assessed the real-world effectiveness and safety of once-daily, fixed-dose combination of Tiotropium/Formoterol/Ciclesonide (TFC) (18 mcg/12 mcg/400 mcg) via dry powder inhaler (DPI) or metered dose inhaler (MDI) in patients with COPD. PATIENTS AND METHODS In this 24-week, open-label, prospective, non-comparative, multicentre, real-world study, COPD patients requiring triple therapy as judged by their physician, were enrolled. The primary endpoint was mean change from baseline in pre-dose Forced Expiratory Volume in 1 s (FEV1) at week 24. Pre and post-dose (30 min) FEV1, Forced Vital capacity (FVC), COPD Assessment Test (CAT), modified Medical Research Council (mMRC) score and safety were also evaluated. A post-hoc analysis was conducted to evaluate the efficacy of the triple drug combination among smoker and non-smoker COPD patients. RESULTS Out of the 297 patients enrolled [mean age 61 ± 10 years; 84.8% males; 55.2% smokers and post-dose FEV1 (% predicted) 39 ± 16%], 253 completed the study. Mean change in pre-dose FEV1 from baseline to week 24 increased significantly after administering the triple drug combination [580 ± 600 mL, 95% CI (510, 650 mL), p < 0.0001]. The increase in the pre-dose FEV1 was significant at all time points (p < 0.0001). Similar improvements were seen in pre-dose FVC, post-dose FEV1 and post-dose FVC across all time points. CAT scores and the proportion of patients with improved mMRC score improved at all visits. The post-hoc analysis showed that TFC significantly increased pre-dose FEV1 both among smokers [mean change 200 ± 430 mL, 95% CI (130, 270 mL), p < 0.0001] as well as non-smokers [990 ± 470 mL, 95% CI (900, 1070 mL), p < 0.0001] at week 24. This difference was significant from week 12 onwards. Mean change in pre and post-dose FEV1 and FVC was significant across all visits between the two groups. At week 24, CAT score reduced significantly from baseline (overall: -6.6 ± 6.07; smokers: -5.17 + 6.96; non-smokers: 8.06 ± 4.44; all p < 0.0001). The mean difference between the two groups was 2.88 (p < 0.0001) at week 24. TFC was well tolerated. CONCLUSION In this real world, multicentre study in India, TFC significantly improved lung function, symptoms and quality of life among all patients with COPD, but the effect was more pronounced among non-smoker COPD patients.
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Affiliation(s)
| | | | | | | | | | - V S Hemalatha
- Sree Narayana Institute of Medical Sciences, Ernakulam, India
| | | | - K P Suraj
- Institute of Chest Diseases, Kozhikode, India
| | | | | | - Paul Thomas
- Madonna Hospital and Research Centre, Ernakulam, India
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14
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Zucchelli A, Vetrano DL, Bianchini E, Lombardo FP, Piraino A, Zibellini M, Ricci A, Marengoni A, Lapi F, Cricelli C. Adherence to COPD free triple inhaled therapy in the real world: a primary care based study. THE CLINICAL RESPIRATORY JOURNAL 2020; 14:732-739. [PMID: 32216053 DOI: 10.1111/crj.13190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 02/25/2020] [Accepted: 03/17/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The development of new pharmacological treatments for chronic obstructive pulmonary disease (COPD) has improved health-related quality of life of patients. However, suboptimal adherence may limit its potential. OBJECTIVE The aim of the present study was to assess the adherence to free triple inhaled therapy and to investigate poor adherence determinants among primary care patients. METHODS Data were derived from a primary care database in Italy. Patients aged 40+ affected by COPD and prescribed with inhaled corticosteroids, long-acting beta agonists and long-acting muscarinic antagonists (N = 3177) were enrolled. Low adherence was defined as a proportion of days covered (PDC) by medications prescription lower than 80%. Predictors of low adherence were tested using logistic regression models. RESULTS AND CONCLUSIONS The 85% of enrolled patients showed poor adherence to free triple inhaled therapy. Comorbidities, such as heart failure (OR 1.78, 95%CI 1.19-2.75), depression (OR 1.41, 95%CI 1.06-1.88) and peripheral vascular disease (OR 1.32, 95%CI 1.01-1.74) were associated with poor adherence. Former (OR 0.52, 95%CI 0.34-0.78) or current smokers (OR 0.61, 95%CI 0.41-0.93) and patients with more severe airways obstruction or history of severe exacerbations (OR 0.64, 95%CI 0.52-0.79) were less likely to exhibit poor adherence. Real-world adherence to triple inhaled therapy with different inhalers is generally low. Higher GOLD airways obstruction stage and current or former smoking status are associated with increased adherence to treatment. Reduced perceived benefit on symptoms control is probably linked to poorer adherence to free triple therapy.
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Affiliation(s)
- Alberto Zucchelli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Davide L Vetrano
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Geriatrics, Catholic University of Rome and IRCCS Fondazione Policlinico "A. Gemelli", Rome, Italy
| | - Elisa Bianchini
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | | | | | | | - Alberto Ricci
- Department of Clinical and Molecular Medicine, S. Andrea Hospital-Sapienza University, Rome, Italy
| | - Alessandra Marengoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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15
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Lopez-Campos JL, Carrasco-Hernandez L, Quintana-Gallego E, Calero-Acuña C, Márquez-Martín E, Ortega-Ruiz F, Soriano JB. Triple therapy for COPD: a crude analysis from a systematic review of the evidence. Ther Adv Respir Dis 2020; 13:1753466619885522. [PMID: 31694491 PMCID: PMC7000908 DOI: 10.1177/1753466619885522] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We systematically reviewed the current knowledge on fixed-dose triple therapies
for the treatment of chronic obstructive pulmonary disease (COPD), with a
specific focus on its efficacy versus single bronchodilation,
double fixed dose combinations, and open triple therapies. Articles were
retrieved from PubMed, Embase, and Scopus up to 3 August 2018. We selected
articles with randomized controlled or crossover design conducted in patients
with COPD and published as full-length articles or scientific letters,
evaluating triple therapy combinations in a single or different inhaler, and
with efficacy data versus monocomponents, double combinations,
or open triple therapies. Our systematic search reported 108 articles, of which
24 trials were finally selected for the analysis. A total of 7 studies with
fixed dose triple therapy combinations, and 17 studies with open triple
therapies combinations. Triple therapy showed improvements in lung function
[trough forced expiratory volume (FEV1) ranging from not significant
(NS) to 147 ml], health status using the St. George’s Respiratory Questionnaire
[(SGRQ) from NS to 8.8 points], and exacerbations [risk ratio (RR) from NS to
0.59 for all exacerbations] versus single or double therapies
with a variability in the response, depending the specific combination, and the
comparison group. The proportion of adverse effects was similar between study
groups, the exception being the increase in pneumonia for some inhaled
corticosteroid (ICS) containing groups. The reviews of this paper are available via the supplementary material
section.
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Affiliation(s)
- Jose Luis Lopez-Campos
- Instituto de Biomedicina de Sevilla (IBiS), Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Avda. Manuel Siurot, s/n., Seville, 41013, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Carrasco-Hernandez
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Esther Quintana-Gallego
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Calero-Acuña
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Eduardo Márquez-Martín
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco Ortega-Ruiz
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan B Soriano
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Madrid, España
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16
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López-Campos JL, Carrasco-Hernández L, Román Rodríguez L, Quintana-Gallego E, Carmona Bernal C, Alcázar Navarrete B. The clinical implications of triple therapy in fixed-dose combination in COPD: from the trial to the patient. Arch Bronconeumol 2020; 56:242-248. [PMID: 35373739 DOI: 10.1016/j.arbr.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/02/2019] [Indexed: 11/19/2022]
Abstract
The emergence of a fixed-dose combination (FDC) of a long-acting ß2-agonist (LABA), a long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid (ICS) in a single inhalation device has changed the approach to inhaled therapy. Although clinical trials describe the efficacy and safety of these FDCs, their use in daily clinical practice can present challenges for the clinician in two specific scenarios. In patients who are already receiving triple therapy via different devices, switching to FDCs could confer benefits by reducing critical errors in the management of inhalers, improving therapeutic adherence, and lowering costs, while maintaining the same clinical efficacy. In patients who are not receiving triple therapy in different devices and who require a change in treatment, triple therapy FDC has shown benefits in clinical trials. Although methodological differences among the trials advise against direct comparison, clinical results show good efficacy, but also considerable variability, and a number of clinical outcomes have yet to be explored. In the future, trials must be developed to complete clinical efficacy data. Real-world efficacy trials are needed, and studies must be designed to determine the profile of patients who present a greater therapeutic response to each FDC in order to pave the way towards more personalized treatment.
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Affiliation(s)
- José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Laura Carrasco-Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Lucas Román Rodríguez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Esther Quintana-Gallego
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Carmona Bernal
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Bernardino Alcázar Navarrete
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Neumología, Hospital de Alta Resolución de Loja, Loja, Granada, Spain
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17
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Lewis HB, Schroeder M, Gunsoy NB, Janssen EM, Llewellyn S, Doll HA, Jones PW, Ismaila AS. Evaluating Patient Preferences of Maintenance Therapy for the Treatment of Chronic Obstructive Pulmonary Disease: A Discrete Choice Experiment in the UK, USA and Germany. Int J Chron Obstruct Pulmon Dis 2020; 15:595-604. [PMID: 32256060 PMCID: PMC7094150 DOI: 10.2147/copd.s221980] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/21/2020] [Indexed: 01/07/2023] Open
Abstract
Introduction With increasing availability of different treatments for chronic obstructive pulmonary disease (COPD), we sought to understand patient preferences for COPD treatment in the UK, USA, and Germany using a discrete choice experiment (DCE). Methods Qualitative research identified six attributes associated with COPD maintenance treatments: ease of inhaler use, exacerbation frequency, frequency of inhaler use, number of different inhalers used, side effect frequency, and out-of-pocket costs. A DCE using these attributes, with three levels each, was designed and tested through cognitive interviews and piloting. It comprised 18 choice sets, selected using a D-efficient experimental design. Demographics and disease history were collected and the final DCE survey was completed online by participants recruited from panels in the UK, USA and Germany. Responses were analyzed using mixed logit models, with results expressed as odds ratios (ORs). Results Overall, 450 participants (150 per country) completed the DCE; most (UK and Germany, 97.3%; USA, 98.0%) were included in the final analysis. Based on relative attribute importance, avoidance of side effects was found to be most important (UK: OR 11.65; USA: OR 7.17; Germany: OR 11.45; all p<0.0001), followed by the likelihood of fewer exacerbations (UK: OR 2.22; USA: OR 1.63; Germany: OR 2.54; all p<0.0001) and increased ease of use (UK: OR 1.84; USA: OR 1.84; Germany: OR 1.60; all p<0.0001). Number of inhalers, out-of-pocket costs, and frequency of inhaler use were found to be less important. Preferences were relatively consistent across the three countries. All participants required a reduction in exacerbations to accept more frequent inhaler use or use of more inhalers. Conclusion When selecting COPD treatment, individuals assigned the highest value to the avoidance of side effects, experiencing fewer exacerbations, and ease of inhaler use. Ensuring that patients’ preferences are considered may encourage treatment compliance.
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Affiliation(s)
| | | | - Necdet B Gunsoy
- Value Evidence and Outcomes, GlaxoSmithKline plc., Uxbridge, UK
| | | | | | | | - Paul W Jones
- Respiratory Therapy Area, GlaxoSmithKline plc., Brentford, UK
| | - Afisi S Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline plc., Collegeville, PA, USA.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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18
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The Clinical Implications of Triple Therapy in Fixed-Dose Combination in COPD: From the Trial to the Patient. Arch Bronconeumol 2020. [PMID: 31983474 DOI: 10.1016/j.arbres.2019.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The emergence of a fixed-dose combination (FDC) of a long-acting β2-agonists (LABAS), a long-acting anticholinergic agent (LAMA), and an inhaled corticosteroid (ICS) in a single inhalation device has changed the approach to inhaled therapy. Although clinical trials describe the efficacy and safety of these FDCs, their use in daily clinical practice can present challenges for the clinician in two specific scenarios. In patients who are already receiving triple therapy via different devices, switching to FDCs could confer benefits by reducing critical errors in the management of inhalers, improving therapeutic adherence, and lowering costs, while maintaining the same clinical efficacy. In patients who are not receiving triple therapy in different devices and who require a change in treatment, triple therapy FDC has shown benefits in clinical trials. Although methodological differences among the trials advise against direct comparison, clinical results show good efficacy, but also considerable variability, and a number of clinical outcomes have yet to be explored. In the future, trials must be developed to complete clinical efficacy data. Real-world efficacy trials are needed, and studies must be designed to determine the profile of patients who present a greater therapeutic response to each FDC in order to pave to way towards more personalized treatment.
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19
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Lai CC, Chen CH, Lin CYH, Wang CY, Wang YH. The effects of single inhaler triple therapy vs single inhaler dual therapy or separate triple therapy for the management of chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Int J Chron Obstruct Pulmon Dis 2019; 14:1539-1548. [PMID: 31371939 PMCID: PMC6628970 DOI: 10.2147/copd.s200846] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/10/2019] [Indexed: 12/20/2022] Open
Abstract
Background This study aims to compare the effects of single inhaler triple therapy comprised of inhaled corticosteroids (ICSs), long-acting β2-agonists (LABAs), and long-acting muscarinic receptor antagonists (LAMAs) with dual therapies comprised of either LABA/LAMA, ICS/LABA or separate ICS/LABA plus LAMA triple therapy. Methods The Pubmed, Embase, and Cochrane databases were searched up to October 31st 2018. Only randomized controlled trials were included in the meta-analysis. The primary outcome was the rate of moderate-to-severe chronic obstructive pulmonary disease (COPD) exacerbations. Results Seven studies fulfilling the inclusion criteria were included in the meta-analysis. Single inhaler triple therapy was associated with a significantly lower risk of COPD exacerbation compared with LABA/LAMA (rate ratio, 0.69; 95% confidence interval [CI] 0.55 to 0.87, I2=85%), and ICS/LABA (rate ratio, 0.81; 95% CI 0.73 to 0.89, I2=29%) dual therapy. Single inhaler triple therapy led to a more significant improvement in lung function and quality of life compared with LABA/LAMA and ICS/LABA dual therapy. Single inhaler triple therapy was associated with a higher risk of pneumonia compared with LABA/LAMA (risk ratio, 1.38, 95% CI 1.14 to 1.67, I2=0) dual therapy. Conclusions The use of single inhaler triple therapy for COPD patients can result in lower rates of moderate or severe exacerbations of COPD as well as improved lung function and quality of life compared with dual therapy with LABA/LAMA or ICS/LABA.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Cheng-Hsin Chen
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Charlotte Yu Hsuan Lin
- Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA, USA
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ya-Hui Wang
- Medical Research Center, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
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20
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Vanfleteren LEGW, Ullman A, Nordenson A, Andersson A, Andelid K, Fabbri LM. Triple therapy (ICS/LABA/LAMA) in COPD: thinking out of the box. ERJ Open Res 2019; 5:00185-2018. [PMID: 30775372 PMCID: PMC6368994 DOI: 10.1183/23120541.00185-2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/19/2018] [Indexed: 01/10/2023] Open
Abstract
A current hot topic in COPD is that two “fixed triple” combinations of an inhaled corticosteroid (ICS), a long-acting β2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) in a single inhaler have become available for patients with COPD, and a third triple therapy is in advanced development with the first large randomised clinical trial (RCT) recently published in Lancet Respiratory Medicine [1]. The triple therapies available in a single inhaler are: beclomethasone-dipropionate/formoterol/glycopyrronium (BDP/FF/G); fluticasone-furoate/vilanterol/umeclidinium (FLF/VI/UMEC); and budesonide/glycopyrronium/formoterol (B/G/F). Triple inhaler therapy in COPD might in some real-life situations be useful outside of the strict indications reported by the registration agencies, but at the same time in some other situations it could be better avoided, even when recommendedhttp://ow.ly/CbOe30njXV2
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Affiliation(s)
- Lowie E G W Vanfleteren
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Anders Ullman
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Anita Nordenson
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Anders Andersson
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Andelid
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Leonardo M Fabbri
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
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Adding a LAMA to ICS/LABA Therapy: A Meta-analysis of Triple Combination Therapy in COPD. Chest 2019; 155:758-770. [PMID: 30660781 DOI: 10.1016/j.chest.2018.12.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/17/2018] [Accepted: 12/14/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) combination is commonly prescribed to treat COPD; therefore, we performed a meta-analysis on the effect of adding a long-acting muscarinic receptor antagonist (LAMA) to ICS/LABA combination in COPD. METHODS Studies were identified by searching in different databases the randomized controlled trials that investigated the effect of ICS/LABA/LAMA combination in COPD. The primary end points were the effect of triple therapy on trough FEV1, risk of acute exacerbation of COPD (AECOPD), and risk of cardiovascular serious adverse events (SAEs), compared with ICS/LABA combination. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the quality of evidence. RESULTS Thirteen randomized controlled trials including 15,519 patients with COPD (ICS/LABA/LAMA combination, 53.1%; ICS/LABA combination, 46.9%) were meta-analyzed. ICS/LABA/LAMA combination improved trough FEV1 (mean difference, +104.86 mL; 95% CI, 86.74-122.99; high quality of evidence) and protected against AECOPD (relative risk, 0.78; 95% CI, 0.71-0.85; high quality of evidence) vs ICS/LABA combination. For every approximately four patients treated with triple therapy, one increased FEV1 > 100 mL, and approximately 26 patients had to be treated for 1 year with ICS/LABA/LAMA combination to prevent one AECOPD, compared with ICS/LABA combination. Adding a LAMA to ICS/LABA therapy did not modulate the risk of cardiovascular SAEs (moderate quality of evidence). CONCLUSIONS Triple therapy provides significant clinical benefit in patients with COPD on ICS/LABA combination. ICS/LABA therapy can be escalated to triple therapy without a real risk to increase cardiovascular SAEs when a LAMA is added to the combination. TRIAL REGISTRY ClinicalTrials.gov; No.: CRD42018095300; URL: www.clinicaltrials.gov.
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Cazzola M, Rogliani P, Calzetta L, Matera MG. Triple therapy versus single and dual long-acting bronchodilator therapy in COPD: a systematic review and meta-analysis. Eur Respir J 2018; 52:13993003.01586-2018. [PMID: 30309975 DOI: 10.1183/13993003.01586-2018] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/03/2018] [Indexed: 01/31/2023]
Abstract
We performed a meta-analysis to compare the impact of triple combination therapy with inhaled corticosteroids (ICS), long-acting β2-agonists (LABAs) and long-acting muscarinic receptor antagonists (LAMAs) versus LABA/LAMA combination therapy or single long-acting bronchodilator therapy in chronic obstructive pulmonary disease. The ICS/LABA/LAMA combination reduced the risk of exacerbation (relative risk 0.70, 95% CI 0.53-0.94) and improved trough forced expiratory volume in 1 s (mean difference in mL +37.94, 95% CI 18.83-53.89) versus LABA/LAMA combination therapy. The protective effect of triple combination therapy versus LABA/LAMA combination therapy against risk of exacerbation was greater in patients with blood eosinophil counts ≥300 cells·µL-1 (relative risk 0.57, 95% CI 0.48-0.68). While ∼38 patients had to be treated for 1 year with ICS/LABA/LAMA combination therapy to prevent one exacerbation compared to LABA/LAMA combination therapy, the number needed to treat (NNT) was ∼21 when compared to single long-acting bronchodilator therapy. The person-based NNT per year of ICS/LABA/LAMA combination therapy versus LABA/LAMA combination therapy was significantly (p<0.05) lower in patients with eosinophil counts ≥300 cells·µL-1 (NNT value: 8.58) than in those with counts <300 cells·µL-1 (NNT value: 46.28). The risk of pneumonia did not differ between ICS/LABA/LAMA combination therapy and its comparators. The number needed to harm was ∼195. This meta-analysis suggests that patients on single long-acting bronchodilator therapy or LABA/LAMA combination therapy, who still have exacerbations and have blood eosinophil counts ≥300 cells·µL-1, could benefit from ICS/LABA/LAMA combination therapy.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Dept of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Medicine, Dept of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Kupczyk M, Kuna P. Beclomethasone dipropionate, formoterol fumarate and glycopyrronium bromide as a combination therapy for chronic obstructive pulmonary disease. Expert Rev Respir Med 2018; 13:5-11. [PMID: 30463457 DOI: 10.1080/17476348.2019.1548937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The triple therapy term covers the combination of inhaled corticosteroid (ICS), long-acting β-receptor agonist (LABA) and long-acting anticholinergic drug (LAMA) in one or in separate inhalers. The latest GOLD 2018 (Global Initiative for Chronic Obstructive Disease) guidelines recommend the triple therapy in the management of chronic obstructive pulmonary disease (COPD) in patients of group D who despite the combination of two drugs: LAMA/LABA or ICS/LABA continue to have persistent symptoms or suffer from further frequent exacerbations. Areas covered: The first triple fixed-dose combination of extrafine beclomethasone/formoterol/glycopyrronium in one pMDI type inhaler intended for the treatment of COPD has been registered in Europe in 2017. Pharmacokinetic and pharmacodynamic properties, clinical efficacy and safety of this triple combination are presented in the review. Expert commentary: A 20% reduction in the risk of moderate or severe exacerbation was found in patients receiving triple therapy compared to the ICS/LABA combination and LAMA monotherapy. Triple therapy reduces the number of exacerbations in comparison with double bronchodilatation (LABA/LAMA), thus representing an interesting therapeutic option in the management of COPD. The profile of side effects of triple therapy is typical for individual active agents included in the combination.
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Affiliation(s)
- Maciej Kupczyk
- a Department of Internal Medicine, Asthma and Allergy , Medical University of Lodz , Lodz , Poland
| | - Piotr Kuna
- a Department of Internal Medicine, Asthma and Allergy , Medical University of Lodz , Lodz , Poland
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Kerwin EM, Tosiello R, Price B, Sanjar S, Goodin T. Effect of background long-acting beta 2-agonist therapy on the efficacy and safety of a novel, nebulized glycopyrrolate in subjects with moderate-to-very-severe COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:2917-2929. [PMID: 30275690 PMCID: PMC6157543 DOI: 10.2147/copd.s172408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Phase III studies demonstrated efficacy and safety of nebulized glycopyrrolate inhalation solution (GLY) in subjects with COPD. Secondary analyses were performed to examine the effect of background long-acting beta2-agonist (LABA) use on the efficacy and safety of nebulized GLY. Methods In two 12-week placebo-controlled studies (GOLDEN 3 and GOLDEN 4) and one 48-week, open-label active-controlled study (GOLDEN 5), a total of 2,379 subjects were stratified by background LABA use (LABA-yes: n=861; LABA-no: n=1,518) and randomized to placebo vs GLY 25 or 50 µg twice daily, or GLY 50 µg twice daily vs tiotropium (TIO) 18 µg once daily. Lung function, patient-reported outcomes, exacerbations, and safety were assessed. Results Compared with placebo, pooled data from the 12-week studies showed significant improvements from baseline with GLY 25 and 50 µg across LABA subgroups in trough FEV1 (LABA-yes: 0.101 and 0.110 L; LABA-no: 0.092 and 0.101 L, respectively; P<0.001) and St George’s Respiratory Questionnaire total score (SGRQ; LABA-yes: −2.957 and −3.888; LABA-no: −3.301 and −2.073, respectively; P<0.05). Incidence of treatment-emergent adverse events (TEAEs) was similar in LABA subgroups, and lower in GLY 25 µg vs placebo. In the 48-week active-controlled study, GLY and TIO both showed improvement from baseline across LABA subgroups in FEV1 (LABA-yes: 0.106 and 0.092 L; LABA-no: 0.096 and 0.096 L, respectively) and in SGRQ total score (LABA-yes: −5.190 and −3.094; LABA-no: −4.368 and −4.821, respectively). Incidence of TEAEs was similar between GLY and TIO, and across LABA subgroups. Exacerbation rates were similar across treatments and LABA subgroups, and cardiovascular events of special interest were more frequent in the LABA-no subgroup. Nebulized GLY, combined with LABA, did not generate any additional safety signals. Conclusion Nebulized GLY demonstrated efficacy and was well tolerated up to 48 weeks in subjects with COPD with/without background LABA.
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Affiliation(s)
- Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Inc., Medford, OR, USA,
| | | | - Barry Price
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
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Singh D. Single inhaler triple therapy with extrafine beclomethasone, formoterol, and glycopyrronium for the treatment of chronic obstructive pulmonary disease. Expert Opin Pharmacother 2018; 19:1279-1287. [PMID: 29985096 DOI: 10.1080/14656566.2018.1498841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) management focuses on the alleviation of symptoms and prevention of exacerbations. Inhaled long acting bronchodilators and inhaled corticosteroids (ICS) are the main classes of treatment for COPD. Triple therapy with a long acting beta2-agonist (LABA), long acting muscarinic antagonist (LAMA), and ICS is commonly prescribed for symptomatic COPD patients experiencing regular exacerbations. Triple therapy is usually administered using separate inhalers; there is little clinical trial evidence of an effect on exacerbation prevention with this approach. Areas covered: This evaluation reviews the single inhaler extrafine combination containing beclometasone diproprionate (BDP), formoterol fumarate (FF), and glycopyrronium bromide (GB) which has been developed as a simplified triple regime. BDP/FF/GB significantly reduced exacerbation rates in three clinical trials (1-year duration) compared against LAMA monotherapy (20% exacerbation reduction), ICS/LABA combination (23% exacerbation reduction), and LAMA/LABA combination (15% exacerbation reduction). Expert opinion: The practical benefits of single inhaler triple therapy in the real world have not been studied. However, the robust clinical trial evidence that BDP/FF/GB reduces exacerbations compared to double combination treatments and LAMA monotherapy cements triple therapy positioning as an escalation step in COPD management pathways.
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Affiliation(s)
- Dave Singh
- a University of Manchester, Medicines Evaluation Unit, The Langley Building, Manchester University NHS Foundation Hospital Trust , Manchester , UK
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Mantero M, Radovanovic D, Santus P, Blasi F. Management of severe COPD exacerbations: focus on beclomethasone dipropionate/formoterol/glycopyrronium bromide. Int J Chron Obstruct Pulmon Dis 2018; 13:2319-2333. [PMID: 30104872 PMCID: PMC6072677 DOI: 10.2147/copd.s147484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The major determinant of the decline in lung function, quality of life, and the increased mortality risk in patients with COPD is represented by severe acute exacerbations of the disease, that is, those requiring patients’ hospitalization, constituting a substantial social and health care burden in terms of morbidity and medical resource utilization. Different long-term therapeutic strategies have been proposed so far in order to prevent and/or reduce the clinical and social impact of these events, the majority of which were extrapolated from trials initially focused on the effect of long-acting muscarinic antagonist and subsequently on the efficacy of long-acting β2-agonists in combination or not with inhaled corticosteroids. The option to employ all three classes of molecules combined, despite the limited amount of evidence in our possession, represents a choice currently proposed by international guidelines; however, current recommendations are often based mainly on observational studies or on the results of secondary outcomes in randomized controlled trials. The present narrative review evaluates the available trials that investigated the efficacy of inhaled therapy to prevent COPD exacerbations and especially severe ones, with a particular focus on beclomethasone dipropionate/formoterol/glycopyrronium bromide fixed dose combination, which is the first treatment that comprises all the three drug classes, specifically tested for the prevention of moderate and severe COPD exacerbations.
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Affiliation(s)
- Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy, .,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Ca' Granda Ospedale Policlinico, Milan, Italy,
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), Pulmonary Unit, University of Milan, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Pulmonary Unit, University of Milan, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy, .,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Ca' Granda Ospedale Policlinico, Milan, Italy,
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