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Duan KI, Spece LJ, Wong ES, Feemster LC, Donovan LM, Griffith MF, Keller TL, Bryant AD, Au DH. Low-Value Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease and the Association with Healthcare Utilization and Costs. Ann Am Thorac Soc 2021; 18:989-996. [PMID: 33290180 PMCID: PMC8456735 DOI: 10.1513/annalsats.202009-1128oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
Rationale: Inhaled corticosteroids (ICS) are not first-line therapy for patients with chronic obstructive pulmonary disease (COPD) at low risk of exacerbations, but they are commonly prescribed despite evidence of harm. We consider ICS prescription in this population to be of "low value." The association of low-value ICS with subsequent healthcare utilization and costs is unknown. Understanding this relationship could inform efforts to reduce the delivery of low-value care. Objectives: To determine whether low-value ICS prescribing is associated with higher outpatient healthcare utilization and costs among patients with COPD who are at low risk of exacerbation. Methods: We performed a cohort study between January 1, 2010, and December 31, 2018, identifying a cohort of veterans with COPD who performed pulmonary function tests (PFTs) at 21 Veterans Affairs medical centers nationwide. Patients were defined as having low exacerbation risk if they experienced less than two outpatient exacerbations and no hospital admissions for COPD in the year before PFTs. Our primary exposure was the receipt of an ICS prescription in the 3 months before the date of PFTs. Our primary outcomes were outpatient utilization and outpatient costs in the 1 year after PFTs. For inference, we generated negative binomial models for utilization and generalized linear models for costs, adjusting for confounders. Results: We identified a total of 31,551 patients with COPD who were at low risk of exacerbation. Of these patients, 9,742 were prescribed low-value ICS (mean [standard deviation (SD)] age, 69 [9] yr), and 21,809 were not prescribed low-value ICS (mean [SD] age, 68 [9] yr). Compared with unexposed patients, those exposed to low-value ICS had 0.53 more encounters per patient per year (95% confidence interval CI, 0.23-0.83) and incurred $154.72 higher costs/patient/year (95% CI, $45.58-$263.86). Conclusions: Low-value ICS prescription was associated with higher subsequent outpatient healthcare utilization and costs. Potential mechanisms for the observed association are that 1) low-value ICS may be a marker of poor respiratory symptom control, 2) there is confounding by indication, or 3) low-value ICS results in increased drug costs or utilization. Health systems should identify low-value ICS prescriptions as a target to improve value-based care.
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Affiliation(s)
- Kevin I. Duan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Laura J. Spece
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Edwin S. Wong
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| | - Laura C. Feemster
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Lucas M. Donovan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Matthew F. Griffith
- Health Services Research and Development, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; and
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, Colorado
| | - Thomas L. Keller
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Alexander D. Bryant
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - David H. Au
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
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2
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Bourbeau J, Bafadhel M, Barnes NC, Compton C, Di Boscio V, Lipson DA, Jones PW, Martin N, Weiss G, Halpin DMG. Benefit/Risk Profile of Single-Inhaler Triple Therapy in COPD. Int J Chron Obstruct Pulmon Dis 2021; 16:499-517. [PMID: 33688176 PMCID: PMC7935340 DOI: 10.2147/copd.s291967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/07/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with major healthcare and socioeconomic burdens. International consortia recommend a personalized approach to treatment and management that aims to reduce both symptom burden and the risk of exacerbations. Recent clinical trials have investigated single-inhaler triple therapy (SITT) with a long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA), and inhaled corticosteroid (ICS) for patients with symptomatic COPD. Here, we review evidence from randomized controlled trials showing the benefits of SITT and weigh these against the reported risk of pneumonia with ICS use. We highlight the challenges associated with cross-trial comparisons of benefit/risk, discuss blood eosinophils as a marker of ICS responsiveness, and summarize current treatment recommendations and the position of SITT in the management of COPD, including potential advantages in terms of improving patient adherence. Evidence from trials of SITT versus dual therapies in symptomatic patients with moderate to very severe airflow limitation and increased risk of exacerbations shows benefits in lung function and patient-reported outcomes. Moreover, the key benefits reported with SITT are significant reductions in exacerbations and hospitalizations, with data also suggesting reduced all-cause mortality. These benefits outweigh the ICS-class effect of higher incidence of study-reported pneumonia compared with LAMA/LABA. Important differences in trial design, baseline population characteristics, such as exacerbation history, and assessment of outcomes, have significant implications for interpreting data from cross-trial comparisons. Current understanding interprets the blood eosinophil count as a continuum that can help predict response to ICS and has utility alongside other clinical factors to aid treatment decision-making. We conclude that treatment decisions in COPD should be guided by an approach that considers benefit versus risk, with early optimization of treatment essential for maximizing long-term benefits and patient outcomes.
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Affiliation(s)
- Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mona Bafadhel
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Neil C Barnes
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- William Harvey Institute, Bart’s and the London School of Medicine and Dentistry, London, UK
| | - Chris Compton
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | | | - David A Lipson
- Clinical Sciences, GlaxoSmithKline, Collegeville, PA, USA
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul W Jones
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- Institute of Infection and Immunity, St George’s, University of London, London, UK
| | - Neil Martin
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- University of Leicester, Leicester, UK
| | - Gudrun Weiss
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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3
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Calzetta L, Ritondo BL, Matera MG, Cazzola M, Rogliani P. Evaluation of fluticasone propionate/salmeterol for the treatment of COPD: a systematic review. Expert Rev Respir Med 2020; 14:621-635. [PMID: 32168461 DOI: 10.1080/17476348.2020.1743180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Introduction: Recently, the generic formulation of FP/SAL FDC has been approved in COPD. Although FP/SAL FDC has been the first long-acting FDC approved in COPD, no systematic review assessed the effect of this combination for the treatment of COPD by considering specifically Phase IV studies. The aim of this review was to systematically assess the effect of FP/SAL FDC in COPD patients enrolled in Phase IV studies.Areas covered: The question of this systematic review was to examine the evidence regarding the impact of FP/SAL FDC for the treatment of COPD by searching for Phase IV studies in the ClinicalTrials.gov database.Expert opinion: Generic drugs represent an effective cost-saving step for health-care budgets in the treatment of COPD and should be used in agreement with current recommendations and prescription accuracy. FP/SAL FDC is recommended for the initiation therapy just in a small percentage of symptomatic patients that are at high risk of exacerbation with blood eosinophil counts ≥300 cells per μl. At follow-up, FP/SAL FDC can be escalated to triple ICS/LABA/LAMA combination or switched to LABA/LAMA combination by considering symptoms, exacerbations, lack of response to ICS, inappropriate original indication, and ICS-related adverse events such as pneumonia.
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Affiliation(s)
- Luigino Calzetta
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | | | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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4
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Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne ST, Wiener RS, Feemster L, Udris E, Au DH, Helfrich CD. De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives. J Gen Intern Med 2020; 35:51-56. [PMID: 31396814 PMCID: PMC6957635 DOI: 10.1007/s11606-019-05193-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/21/2018] [Accepted: 05/23/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. OBJECTIVE We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. DESIGN We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. PARTICIPANTS We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. MAIN MEASURES Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. KEY RESULTS Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. CONCLUSIONS Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.
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Affiliation(s)
- Krysttel Stryczek
- VA Northeast Ohio Healthcare System, Cleveland, OH, USA.,Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Colby Lea
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Chris Gillespie
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
| | - George Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | | | - Seppo T Rinne
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA.,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA.,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Laura Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Edmunds Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA. .,Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
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5
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Montes de Oca M, López Varela MV, Acuña A, Schiavi E, Casas A, Tokumoto A, Torres Duque CA, Ramírez-Venegas A, García G, Camelier A, Bergna M, Cohen M, Sanchez-Angarita E, Guzmán S, Czischke K, Barros M, Rey A. Incorporating New Evidence on Inhaled Medications in COPD. The Latin American Chest Association (ALAT) 2019. Arch Bronconeumol 2019; 56:106-113. [PMID: 31767208 DOI: 10.1016/j.arbres.2019.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/30/2019] [Accepted: 09/11/2019] [Indexed: 02/07/2023]
Abstract
This document on COPD from the Latin American Chest Association (ALAT-2019) uses PICO methodology to analyze new evidence on inhaled medication and answer clinical questions. The following key points emerged from this analysis: 1) evidence is lacking on the comparison of short-acting vs. long-acting bronchodilators in patients with mild COPD; patients with moderate-to-severe COPD obtain greater benefit from long-acting bronchodilators; 2) the benefits of monotherapy with long-acting antimuscarinic agents (LAMA) and combined therapy with long-acting β2-agonists and inhaled corticosteroids (LABA/ICS) are similar, although the latter is associated with a greater risk of pneumonia; 3) LABA/LAMA offer greater benefits in terms of lung function and risk of exacerbation than LABA/ICS (the latter involve an increased risk of pneumonia), 4) LAMA/LABA/ICS have greater therapeutic benefits than LABA/LAMA on the risk of moderate-severe exacerbations. With regard to the role of eosinophils in guiding the use of ICS, ICS withdrawal must be considered when the initial indication was wrong or no response is elicited, in patients with side effects such as pneumonia, and in patients with a low risk of exacerbation and an eosinophil blood count of <300 cells/μl. All this evidence, categorized according to the severity of the obstruction, symptoms, and risk of exacerbations, has been used to generate an algorithm for the use of inhaled medication in COPD.
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Affiliation(s)
- María Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela.
| | | | - Agustín Acuña
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela; Departamento de Investigación y Estadística, ITSalud/Medsolid, Caracas, Venezuela
| | - Eduardo Schiavi
- SubSecretaría de Planificación Sanitaria, Ministerio de Salud, Gobierno de la Ciudad Autónoma de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | | | | | | | - Aquiles Camelier
- Universidade do Estado da Bahia e Escola Bahiana de Medicina, Salvador, Brasil
| | - Miguel Bergna
- Hospital Dr. Antonio Cetrángolo, Vicente López, Buenos Aires, Argentina
| | - Mark Cohen
- Hospital Centro Médico, Guatemala, Guatemala
| | - Efraín Sanchez-Angarita
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela; Departamento de Investigación y Estadística, ITSalud/Medsolid, Caracas, Venezuela
| | | | - Karen Czischke
- Clínica Alemana de Santiago, Hospital Padre Hurtado, Universidad del Desarrollo, San Ramón, Región Metropolitana, Chile
| | - Manuel Barros
- Escuela de Medicina, Universidad de Valparaíso, Hospital C. Van Buren, Valparaíso, Región de Valparaíso, Chile
| | - Alejandra Rey
- Universidad de la República, Hospital Maciel, Montevideo, Uruguay
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6
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Lee KC, Wu YT, Chen LC, Shen CH, Chung CH, Chien WC, Shieh YS. Chronic obstructive pulmonary disease combined with vertebral compression fracture increases the risk of temporomandibular disorder: A population-based cohort study. Medicine (Baltimore) 2019; 98:e17162. [PMID: 31517866 PMCID: PMC6750274 DOI: 10.1097/md.0000000000017162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Vertebral compression fracture (VCF) is a common comorbidity of chronic obstructive pulmonary disease (COPD), and the coexistence of COPD and temporomandibular disorder (TMD) has been clinically noted. The present study aimed to investigate whether VCF increases the risk of TMD in patients with COPD.With a follow-up period of 15 years, this retrospective, population-based longitudinal cohort study enrolled sex- and age-matched COPD patients with and without VCF (1:3) who were identified from Taiwan's National Health Insurance Research Database from 2000 to 2015. Multivariate Cox regression analysis was performed to determine the risk of TMD in COPD patients with and without VCF. The cumulative risk of TMD between groups was estimated using Kaplan-Meier analysis.The risk factors for TMD in patients with COPD were VCF, osteoporosis, and winter season. The COPD with VCF group was more likely to develop TMD (adjusted hazard ratio = 3.011, P < .001) than the COPD without VCF group after adjustment for sex, age, variables, and comorbidities. In the subgroup analysis, the COPD with VCF group had a higher risk of TMD than the COPD without VCF group in almost all stratifications.COPD patients with VCF are at a higher risk of developing TMD. Clinicians taking care of patients with COPD should be aware of the occurrence of TMD as a comorbidity.
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Affiliation(s)
- Kuei-Chen Lee
- Graduate Institute of Medical Sciences
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital
| | - Yung-Tsan Wu
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital
| | - Liang-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital
| | - Chih-Hao Shen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital
| | - Chi-Hsiang Chung
- School of Public Health
- Department of Medical Research, Tri-Service General Hospital
| | - Wu-Chien Chien
- School of Public Health
- Department of Medical Research, Tri-Service General Hospital
- Graduate Institute of Life Science, National Defense Medical Center
| | - Yi-Shing Shieh
- Graduate Institute of Medical Sciences
- Department of Dentistry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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7
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Okauchi S, Kinoshita K, Sato S, Osawa H, Yamada H, Miyazaki K, Satoh H, Hizawa N, Kobayashi H. Rinsing of oropharynx and storage place of respiratory medicine inhaler: A cross-sectional audit. J Gen Fam Med 2019; 20:101-106. [PMID: 31065474 PMCID: PMC6498108 DOI: 10.1002/jgf2.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/21/2019] [Accepted: 02/25/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In patients with bronchial asthma and those with chronic obstructive pulmonary disease (COPD), inhalation therapy and rinsing of the mouth and the oropharynx by gargling ("RMOG") after inhalation are recommended. We performed a cross-sectional audit aimed at investigating (a) the proportion of patients performing "RMOG" after inhalation and (b) storage place of patients' inhaler. METHODS Patients with bronchial asthma and those with COPD were asked by medical aids at outpatient visits whether they did "RMOG every time," "RMOG sometimes," or "no RMOG" after inhalation, and where they stored their inhaler. RESULTS During a six month study period up to September 2017, 330 consecutive patients with asthma and those with COPD were included in the study. Two hundred and thirty-two (70.3%) of the 330 patients answered "RMOG every time" and 98 (29.7%) of them did "RMOG sometimes" and did "no RMOG." There was a difference in the proportion of patients performing RMOG after inhalation with patient age. With regard to the storage location of inhaler, we found the proportion of patients performing RMOG was higher in those who stored inhalers in a room with running water than in those who stored inhalers at other places. This difference was found in patients with both bronchial asthma and those with COPD. CONCLUSIONS Further implementation of "patient education" on performing RMOG after inhalation for patients receiving inhaled medication is still necessary. Our results suggest that it is better to store inhalers in places where there is easy access to tap water used for RMOG.
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Affiliation(s)
- Shinichiro Okauchi
- Division of Respiratory MedicineMito Medical CenterUniversity of TsukubaMitoJapan
| | - Kensuke Kinoshita
- Division of General MedicineMito Medical CenterUniversity of TsukubaMitoJapan
| | - Shinya Sato
- Division of Respiratory MedicineRyugasaki Saiseikai HospitalRyugasakiJapan
| | - Hajime Osawa
- Division of Respiratory MedicineMito Medical CenterUniversity of TsukubaMitoJapan
| | - Hideyasu Yamada
- Division of Respiratory MedicineHitachinaka General HospitalHitachinakaHitachinaka
| | - Kunihiko Miyazaki
- Division of Respiratory MedicineRyugasaki Saiseikai HospitalRyugasakiJapan
| | - Hiroaki Satoh
- Division of Respiratory MedicineMito Medical CenterUniversity of TsukubaMitoJapan
| | - Nobuyuki Hizawa
- Division of Respiratory MedicineFaculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Hiroyuki Kobayashi
- Division of General MedicineMito Medical CenterUniversity of TsukubaMitoJapan
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8
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Gonçalves PA, Dos Santos Neves R, Neto LV, Madeira M, Guimarães FS, Mendonça LMC, Lopes AJ, Farias MLF. Inhaled glucocorticoids are associated with vertebral fractures in COPD patients. J Bone Miner Metab 2018; 36:454-461. [PMID: 28766137 DOI: 10.1007/s00774-017-0854-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/20/2017] [Indexed: 11/29/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is an independent risk factor for osteoporosis. Oral glucocorticoids are deleterious to bone; however, the impact of inhaled glucocorticoids (ICS) remains unclear. Our objective was to determine whether ICS contribute to osteoporosis and fragility fractures. Sixty-one COPD patients, 35 current users of ICS and 26 who had never received glucocorticoids, were evaluated for bone mineral density (BMD) and body composition and underwent vertebral fracture assessment (VFA). The risk factors for bone disease considered for analysis were age, gender, ICS use, body mass index (BMI), muscle mass index (MMI), and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) category. The Fracture Risk Assessment Tool (FRAX) calculation tool for the Brazilian population was also employed. The groups did not differ regarding gender, BMI, MMI, GOLD class, lowest values of the BMD T-score and Z-score, prevalence of osteoporosis, or low BMD for age. Vertebral fractures were identified via VFA in seven patients using ICS and in none of those not receiving glucocorticoids (p = 0.02). There was a trend for an association between MMI and osteoporosis (p = 0.05) and for a progressive decrease in the BMD Z-score according to the COPD severity assessed via the GOLD score (p = 0.08). Vertebral fractures were not associated with osteoporosis (p = 0.69) or low MMI (p = 0.12). The fracture risk was not estimated by FRAX. ICS may lead to bone fragility before a significant decrease in BMD. Low muscle mass and COPD severity may contribute to bone disease.
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Affiliation(s)
- Pedro Assed Gonçalves
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil.
| | - Rafael Dos Santos Neves
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil
| | - Miguel Madeira
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil
| | - Fernando Silva Guimarães
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | | | - Agnaldo Jose Lopes
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
- Division of Pneumology, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Maria Lucia Fleiuss Farias
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil
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9
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Koehorst-Ter Huurne K, Groothuis-Oudshoorn CG, vanderValk PD, Movig KL, van der Palen J, Brusse-Keizer M. Association between poor therapy adherence to inhaled corticosteroids and tiotropium and morbidity and mortality in patients with COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1683-1690. [PMID: 29872286 PMCID: PMC5973470 DOI: 10.2147/copd.s161374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim The aim of this study was to analyze the association between therapy adherence to inhaled corticosteroids (ICSs) and tiotropium on the one hand and morbidity and mortality in COPD on the other hand. Methods Therapy adherence to ICSs and tiotropium over a 3-year period of, respectively, 635 and 505 patients was collected from pharmacy records. It was expressed as percentage and deemed optimal at ≥75-≤125%, suboptimal at ≥50%-<75%, and poor at <50% (underuse) or >125% (overuse). The association between adherence and time to first hospital admission for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), community acquired pneumonia (CAP), and mortality was analyzed, with optimal use as the reference category. Results Suboptimal use and underuse of ICSs and tiotropium were associated with a substantial increase in mortality risk: hazard ratio (HR) of ICSs was 2.9 (95% CI 1.7-5.1) and 5.3 (95% CI 3.3-8.5) and HR of tiotropium was 3.9 (95% CI 2.1-7.5) and 6.4 (95% CI 3.8-10.8) for suboptimal use and underuse, respectively. Suboptimal use and overuse of tiotropium were also associated with an increased risk of CAP, HR 2.2 (95% CI 1.2-4.0) and HR 2.3 (95% CI 1.2-4.7), respectively. Nonadherence to tiotropium was also associated with an increased risk of severe AECOPD: suboptimal use HR 3.0 (95% CI 2.01-4.5), underuse HR 1.9 (95% CI 1.2-3.1), and overuse HR 1.84 (95% CI 1.1-3.1). Nonadherence to ICSs was not related to time to first AECOPD or first CAP. Conclusion Poor adherence to ICSs and tiotropium was associated with a higher mortality risk. Furthermore, nonadherence to tiotropium was associated with a higher morbidity. The question remains whether improving adherence can reduce morbidity and mortality.
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Affiliation(s)
| | | | - Paul Dlpm vanderValk
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Kris Ll Movig
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Research Methodology, Measurement, and Data Analysis, University of Twente, Enschede, the Netherlands
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10
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Hahn B, Hull M, Blauer-Peterson C, Buikema AR, Ray R, Stanford RH. Rates of escalation to triple COPD therapy among incident users of LAMA and LAMA/LABA. Respir Med 2018; 139:65-71. [PMID: 29858004 DOI: 10.1016/j.rmed.2018.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/19/2018] [Accepted: 04/18/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Improved outcomes have been reported for patients with chronic obstructive pulmonary disease (COPD) receiving combination long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) therapy compared with LAMA monotherapy. However, little is known about the relative characteristics of these patients and their rates of escalation to triple therapy (TT, combining a LAMA, LABA, and inhaled corticosteroid). This study aimed to characterize patients initiating treatment with the LAMA tiotropium (TIO) and the fixed-dose LAMA/LABA combination therapy umeclidinium/vilanterol (UMEC/VI), and to compare rates of escalation to TT between patients receiving these therapies. METHODS Retrospective study of patients with COPD enrolled in a US health insurance plan during 2013-2015 and newly initiated on TIO or UMEC/VI. Patients were ≥40 years of age at index (date of therapy initiation) with continuous enrollment for 12 months pre-index and ≥30 days post-index. LAMA users were propensity score matched 1:1 to LAMA/LABA users, with TT initiation rates reported by cohort using pharmacy claims. RESULTS 35,357 patients initiating on TIO and 2407 patients initiating on UMEC/VI were identified. After propensity score matching, the rate of TT initiation was significantly higher in new TIO users (n = 1320) than in new UMEC/VI users (n = 1320) (0.92 vs 0.49 per 100 months of exposure, respectively; p < 0.001). Relative to the UMEC/VI cohort, the TIO cohort had an 87% higher risk of TT initiation (hazard ratio: 1.87; 95% confidence interval: 1.4-2.5; p = 0.001). CONCLUSIONS Patients receiving UMEC/VI progressed to TT more slowly, and were at lower risk of progressing to TT, than patients receiving TIO.
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Affiliation(s)
- Beth Hahn
- US Value Evidence and Outcomes, GSK, 5 Moore Drive, Research Triangle Park, NC 27709-3398, USA.
| | - Michael Hull
- Health Economics and Outcomes Research, Optum LifeSciences, 11000 Optum Circle, MN101-E300, Eden Prairie, MN 55344, USA.
| | - Cori Blauer-Peterson
- Health Economics and Outcomes Research, Optum LifeSciences, 11000 Optum Circle, MN101-E300, Eden Prairie, MN 55344, USA.
| | - Ami R Buikema
- Health Economics and Outcomes Research, Optum LifeSciences, 11000 Optum Circle, MN101-E300, Eden Prairie, MN 55344, USA.
| | - Riju Ray
- US Medical Affairs, GSK, 5 Moore Drive, Research Triangle Park, NC 27709-3398, USA.
| | - Richard H Stanford
- US Value Evidence and Outcomes, GSK, 5 Moore Drive, Research Triangle Park, NC 27709-3398, USA.
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11
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Calverley PMA, Magnussen H, Miravitlles M, Wedzicha JA. Triple Therapy in COPD: What We Know and What We Don't. COPD 2017; 14:648-662. [DOI: 10.1080/15412555.2017.1389875] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Centre for Lung Research, Grosshansdorf, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Jadwiga A. Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
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12
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Cazeiro C, Silva C, Mayer S, Mariany V, Wainwright CE, Zhang L. Inhaled Corticosteroids and Respiratory Infections in Children With Asthma: A Meta-analysis. Pediatrics 2017; 139:peds.2016-3271. [PMID: 28235797 DOI: 10.1542/peds.2016-3271] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in adult patients with chronic obstructive pulmonary disease. OBJECTIVE To assess the association between ICS use and risk of pneumonia and other respiratory infections in children with asthma. DATA SOURCES We searched PubMed from inception until May 2015. We also searched clinicaltrials.gov and databases of pharmaceutical manufacturers. STUDY SELECTION We selected randomized trials that compared ICS with placebo for at least 4 weeks in children with asthma. DATA EXTRACTION We included 39 trials, of which 31 trials with 11 615 patients contributed data to meta-analyses. RESULTS The incidence of pneumonia was 0.58% (44/7465) in the ICS group and 1.51% (63/4150) in the placebo group. The meta-analysis of 9 trials that revealed at least 1 event of pneumonia revealed a reduced risk of pneumonia in patients taking ICS (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.44 to 0.94). Using risk difference as effect measure, the meta-analysis including all 31 trials revealed no significant difference in the risk of pneumonia between the ICS and placebo groups (risk difference: -0.1%; 95% CI: -0.3% to 0.2%). No significant association was found between ICS and risk of pharyngitis (RR: 1.01; 95% CI: 0.87 to 1.18), otitis media (RR: 1.07; 95% CI: 0.83 to 1.37), and sinusitis (RR: 0.89; 95% CI: 0.76 to 1.05). LIMITATIONS Lack of clearly defined criteria for respiratory infections and possible publication bias. CONCLUSIONS Regular use of ICS may not increase the risk of pneumonia or other respiratory infections in children with asthma.
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Affiliation(s)
| | - Cristina Silva
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil; and
| | - Susana Mayer
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil; and
| | - Vanessa Mariany
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil; and
| | - Claire Elizabeth Wainwright
- Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital and School of Medicine, The University of Queensland, Brisbane, Australia
| | - Linjie Zhang
- Postgraduate Program in Public Health, .,Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil; and.,Postgraduate Program in Health Science, and
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13
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Ranjani R, Vinotha ATS. A prospective randomized controlled study: Theophylline on oxidative stress and steroid sensitivity in chronic obstructive pulmonary disease patients. Int J Pharm Investig 2017; 7:119-124. [PMID: 29184823 PMCID: PMC5680646 DOI: 10.4103/jphi.jphi_58_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective: Oxidative stress is involved in the pathogenesis of chronic obstructive pulmonary disease (COPD). Corticosteroid fails to suppress inflammation and oxidative stress due to steroid resistance. Theophylline has an effect on histone deacetylase (HDAC) activity and improves steroid sensitivity in COPD. Given changes in oxidative stress associated with diminished corticosteroid effects, a clinical study in which antioxidants and free radicals are estimated can suggest a correlation between antioxidants, theophylline, and corticosteroid sensitivity. Materials and Methods: A randomized controlled study was conducted in 60 participants divided into 4 groups: Group I (controls) - 15 normal healthy volunteers, Group II - COPD patients who received theophylline 300 mg + salbutamol 8 mg, Group III - patients who inhaled budesonide 400 μg + salbutamol 8 mg, and Group IV – theophylline 300 mg + inhaled budesonide 400 μg + salbutamol 8 mg 12 weeks. Blood samples were collected at the time of diagnosis and at 4-week interval for 3 months from all the groups and antioxidant parameters, spirometric % forced expiratory volume in 1 s (FEV1) were measured. Results: The mean difference between groups was analyzed using one-way ANOVA. There was a significant increase in antioxidant enzymes such as catalase, glutathione (GSH) serum transferase, (P < 0.05), reduced GSH, and superoxide dismutase (P < 0.01) and a significant decrease in lipid peroxidation (P < 0.01) at 12 weeks of the study period. Postbronchodilator FEV1 values have also shown a significant increase at 12 weeks (P < 0.01). Conclusion: Theophylline increases the expression and activity of HDAC and improves steroid sensitivity thereby decreases oxidative stress. Hence, novel therapeutic strategy is therefore the reversal of this corticosteroid resistance by increasing the expression and activity of HDAC achieved using corticosteroids along with theophylline.
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Affiliation(s)
- R Ranjani
- Department of Pharmacology, Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India
| | - A T Sathiya Vinotha
- Department of Pharmacology, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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14
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Perrone V, Sangiorgi D, Buda S, Degli Esposti L. Comparative analysis of budesonide/formoterol and fluticasone/salmeterol combinations in COPD patients: findings from a real-world analysis in an Italian setting. Int J Chron Obstruct Pulmon Dis 2016; 11:2749-2755. [PMID: 27853362 PMCID: PMC5104304 DOI: 10.2147/copd.s114554] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIM The objective of this study was to evaluate the different outcomes associated with the use of budesonide/formoterol compared to fluticasone/salmeterol in fixed combinations in patients with COPD in a "real-world" setting. The outcomes included exacerbation rates and health care costs. PATIENTS AND METHODS An observational retrospective cohort analysis, based on administrative databases of three local health units, was conducted. Patients with at least one prescription of fixed-dose combination of inhaled corticosteroids and long-acting β2-agonists (budesonide/formoterol or fluticasone/salmeterol), at dosages and formulations approved for COPD in Italy, between January 1, 2009 and December 31, 2011 (inclusion period), were included. Patients were followed until December 2012, death or end of treatment (follow-up period), whichever occurred first. Patients were included if they were aged ≥40 years and had at least 6 months of follow-up. Propensity score matching was performed to check for confounding effects. Number of hospitalizations for COPD and number of oral corticosteroid and antibiotic prescriptions during follow-up were analyzed using Poisson regression models. The cost analysis was conducted from the perspective of the National Health System. RESULTS After matching, 4,680 patients were analyzed, of which 50% were males with a mean age of 64±13 years. In the Poisson regression models, the incidence rate ratio for budesonide/formoterol as compared to fluticasone/salmeterol was 0.84 (95% confidence interval [CI]: 0.74-0.96, P=0.010) for number of hospitalizations, 0.89 (95% CI: 0.87-0.92, P<0.001) for number of oral corticosteroid prescriptions and 0.88 (95% CI: 0.86-0.89, P<0.001) for number of antibiotic prescriptions. The mean annual expenditure for COPD management was €2,436 for patients treated with budesonide/formoterol and €2,784 for patients treated with fluticasone/salmeterol. CONCLUSION Among patients with COPD, treatment with a fixed combination of budesonide/formoterol was associated with fewer exacerbations and a lower, but not significant, cost of illness than the treatment with fluticasone/salmeterol. Real-world analyses are requested to ameliorate interventions to address unmet needs, optimizing treatment pathways to improve COPD-related burden and outcomes.
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Affiliation(s)
- Valentina Perrone
- CliCon S.r.l. Health, Economics and Outcomes Research, Ravenna, Italy
| | - Diego Sangiorgi
- CliCon S.r.l. Health, Economics and Outcomes Research, Ravenna, Italy
| | - Stefano Buda
- CliCon S.r.l. Health, Economics and Outcomes Research, Ravenna, Italy
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15
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Vogelmeier C, Paggiaro PL, Dorca J, Sliwinski P, Mallet M, Kirsten AM, Beier J, Seoane B, Segarra RM, Leselbaum A. Efficacy and safety of aclidinium/formoterol versus salmeterol/fluticasone: a phase 3 COPD study. Eur Respir J 2016; 48:1030-1039. [DOI: 10.1183/13993003.00216-2016] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 06/03/2016] [Indexed: 12/22/2022]
Abstract
The efficacy and safety of twice-daily aclidinium bromide/formoterol fumarate was compared with that of salmeterol/fluticasone propionate in patients with stable, moderate-to-severe chronic obstructive pulmonary disease (COPD).AFFIRM COPD (Aclidinium and Formoterol Findings in Respiratory Medicine COPD) was a 24-week, double-blind, double-dummy, active-controlled study. Patients were randomised (1:1) to aclidinium/formoterol 400/12 µg twice-daily via Genuair/Pressair or salmeterol/fluticasone 50/500 µg twice-daily via Accuhaler. The primary end-point was peak forced expiratory volume in 1 s (FEV1) at week 24. Other end-points included Transition Dyspnoea Index (TDI) focal score at week 24, TDI and St George's Respiratory Questionnaire (SGRQ) responders, COPD Assessment Test and SGRQ scores, assessment of COPD symptoms and exacerbations, use of reliever medication, and device preference. Adverse events were monitored throughout.In total, 933 patients were eligible (mean age 63.4 years, 65.1% male). Aclidinium/formoterol was superior to salmeterol/fluticasone in peak FEV1 and noninferior in TDI. Health status and reduction in exacerbation risk were similar in both groups. While both treatments were well tolerated, pneumonia occurred less frequently with aclidinium/formoterol than salmeterol/fluticasone.In stable COPD, aclidinium/formoterol significantly improved bronchodilation versus salmeterol/fluticasone, with equivalent benefits in symptom control and reduction in exacerbation risk. Both treatments were well tolerated and treatment-related adverse events were less common with aclidinium/formoterol.
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16
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Du W, Su J, Ye D, Wang Y, Huang Q, Gong X. Pinellia ternata Attenuates Mucus Secretion and Airway Inflammation after Inhaled Corticosteroid Withdrawal in COPD Rats. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2016; 44:1027-41. [PMID: 27430907 DOI: 10.1142/s0192415x16500579] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Inhaled corticosteroids (ICS) are widely used to manage chronic obstructive pulmonary disease (COPD). However, withdrawal of ICS generally causes various adverse effects, warranting careful management of the ICS withdrawal. Pinellia ternata, a traditional Chinese herbal medicine, has been used to treat respiratory diseases in China for centuries. Here, we investigated its role in antagonizing ICS withdrawal-induced side effects, and explored the underlying mechanisms. The rat COPD model was established using a combination of passive cigarette smoking and intratracheal instillation of lipopolysaccharide (LPS). COPD rats were treated with saline or budesonide inhalation, or with budesonide inhalation followed by saline inhalation or Pinellia ternata gavage. The number of goblet cells and the level of mucin 5AC (MUC5AC) were enhanced by budesonide withdrawal. Pinellia ternata treatment significantly blocked these effects. Further, Pinellia ternata treatment reversed budesonide withdrawal-induced increase of interleukin 1[Formula: see text] (IL-1[Formula: see text] and tumor necrosis factor [Formula: see text] (TNF-[Formula: see text]) levels in bronchoalveolar lavage fluid (BALF). Extracellular signal-regulated kinase (ERK), but neither p38 nor c-Jun N-terminal kinase (JNK), was activated by budesonide withdrawal, and the activation was blocked by Pinellia ternata treatment. The MUC5AC expression was positively correlated with goblet cell number, IL-1[Formula: see text] and TNF-[Formula: see text] levels, and ERK activity. Pinellia ternata treatment protected the airway from ICS withdrawal-induced mucus hypersecretion and airway inflammation by inhibiting ERK activation. Pinellia ternata treatment may represent a novel therapeutic strategy to prevent ICS withdrawal-induced side effects in COPD patients.
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Affiliation(s)
- Wei Du
- * Department of Pathophysiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.,‡ Respiratory Diseases Group, the 6th Unit, Department of Internal Medicine, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou 510010, China
| | - Jinyu Su
- * Department of Pathophysiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Dan Ye
- § Hexian Memorial Hospital, Panyu, Guangzhou 511400, China
| | - Yuegang Wang
- † Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Qiaobing Huang
- * Department of Pathophysiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xiaowei Gong
- * Department of Pathophysiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.,¶ Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge 14183, Sweden
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17
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Bryant L. Nuggets of Knowledge: COPD – targeting the use of inhaled corticosteroids. J Prim Health Care 2016; 8:83-5. [DOI: 10.1071/hc15902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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