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Gadhvi K, Kandeil M, Raveendran D, Choi J, Davies N, Nanchahal S, Wing O, Quint J, Whittaker H. Inhaled Corticosteroids and Risk of Cardiovascular Disease in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Regression. Chronic Obstr Pulm Dis 2023; 10:317-327. [PMID: 37289196 PMCID: PMC10484493 DOI: 10.15326/jcopdf.2022.0386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/09/2023]
Abstract
Background Previous studies have reported mixed associations between inhaled corticosteroids (ICSs) and cardiovascular disease (CVD) in people with chronic obstructive pulmonary disease (COPD). Using updated literature, we investigated the association between ICS-containing medications and CVD in COPD patients, stratified by study-related factors. Methods We searched MEDLINE and EMBASE for studies that reported effect estimates for the association between ICS-containing medications and the risk of CVD in COPD patients. CVD outcomes specifically included heart failure, myocardial infarction, and stroke-related events. We conducted a random-effects meta-analysis and a meta-regression to identify effect-modifying study-related factors. Results Fifteen studies met inclusion criteria and investigated the association between ICS-containing medications and the risk of CVD. Pooled results from our meta-analysis showed a significant association between ICS-containing medication and reduced risk of CVD (hazard ratio 0.87, 95% confidence intervals 0.78 to 0.97). Study follow-up time, non-ICS comparator, and exclusion of patients with previous CVD modified the association between ICS use and risk of CVD. Conclusions Overall, we found an association between ICS-containing medications and reduced risk of CVD in COPD patients. Results from the meta-regression suggest that subgroups of COPD patients may benefit from ICS use more than others and further work is needed to determine this.
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Affiliation(s)
- Krishna Gadhvi
- Faculty of Medicine, Imperial College London, London, United Kingdom
- *joint first authors
| | - Minnah Kandeil
- Faculty of Medicine, Imperial College London, London, United Kingdom
- *joint first authors
| | - Dinushan Raveendran
- Faculty of Medicine, Imperial College London, London, United Kingdom
- *joint first authors
| | - Jeewoo Choi
- Faculty of Medicine, Imperial College London, London, United Kingdom
- *joint first authors
| | - Nia Davies
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Sukanya Nanchahal
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Oliva Wing
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jennifer Quint
- School of Public Health and the National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Hannah Whittaker
- School of Public Health and the National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Almagro P, Martinez-Camblor P. Comment on: Combination therapy with long-acting bronchodilators and the risk of major adverse cardiovascular events in patients with COPD: a systematic review and meta-analysis. Eur Respir J 2023; 61:13993003.02208-2022. [PMID: 36549702 DOI: 10.1183/13993003.02208-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Pere Almagro
- Internal Medicine Department, University Hospital Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Faculty of Health Sciences, Universidad Autonoma de Chile, Providencia, Chile
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Yang MJ, Guo SL, Sin DD. Reply: Association between triple therapy and major adverse cardiovascular events in COPD patients. Eur Respir J 2023; 61:13993003.02332-2022. [PMID: 36549713 DOI: 10.1183/13993003.02332-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Ming-Jin Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shu-Liang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Shu-Liang Guo and Don D. Sin contributed equally to this article as lead authors and supervised the work
| | - Don D Sin
- Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, University of British Columbia, and St. Paul's Hospital, Vancouver, BC, Canada
- Shu-Liang Guo and Don D. Sin contributed equally to this article as lead authors and supervised the work
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Calderón Montero A. [Cardiopulmonary axis and cardiovascular mortality in patients with COPD]. Semergen 2023; 49:101928. [PMID: 36796228 DOI: 10.1016/j.semerg.2023.101928] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/16/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of mortality in our environment and was usually considered to be confined to the lung territory. The latest studies suggest that it is a systemic disease whose most probable etiopathogenesis is a state of low-intensity chronic inflammation that worsens during exacerbations. And recent scientific evidence has highlighted that cardiovascular diseases are one of the main causes of hospitalization and mortality in these patients. This relationship must be understood considering that both systems, the pulmonary and the cardiovascular, are closely related constituting the cardiopulmonary axis. Therefore, the therapeutic approach to COPD should not only include the treatment of respiratory complications, but also the prevention and treatment of cardiovascular diseases, which are very common in these patients. In this sense, in the last years, studies have been carried out that analyze the effect of the different types of inhaled therapy on all-cause mortality and cardiovascular mortality in particular.
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Wells JM, Criner GJ, Halpin DMG, Han MK, Jain R, Lange P, Lipson DA, Martinez FJ, Midwinter D, Singh D, Wise RA. Mortality Risk and Serious Cardiopulmonary Events in Moderate-to-Severe COPD: Post Hoc Analysis of the IMPACT Trial. Chronic Obstr Pulm Dis 2023; 10:33-45. [PMID: 36516330 PMCID: PMC9995234 DOI: 10.15326/jcopdf.2022.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background In the InforMing the Pathway of COPD Treatment (IMPACT) trial, single-inhaler fluticasone furoate (FF) /umeclidinium (UMEC) /vilanterol (VI) significantly reduced severe exacerbation rates and all-cause mortality (ACM) risk versus UMEC/VI among patients with chronic obstructive pulmonary disease (COPD). This post hoc analysis aimed to define the risk of ACM during and following a moderate/severe exacerbation, and further determine the benefit-risk profile of FF/UMEC/VI versus FF/VI and UMEC/VI using a cardiopulmonary composite adverse event (AE) endpoint. Methods The 52-week, double-blind IMPACT trial randomized patients with symptomatic COPD and ≥1 exacerbation in the prior year 2:2:1 to once-daily FF/UMEC/VI 100/62.5/25mcg, FF/VI 100/25mcg, or UMEC/VI 62.5/25mcg. Post hoc endpoints included the risk of ACM during, 1-90 and 91-365 days post moderate or severe exacerbation and time-to-first cardiopulmonary composite event. Results Of the 10,355 patients included, 5034 (49%) experienced moderate/severe exacerbations. Risk of ACM was significantly increased during a severe exacerbation event compared with baseline (hazard ratio [HR]: 41.22 [95% confidence interval (CI) 26.49-64.15]; p<0.001) but not significantly different at 1-90 days post-severe exacerbation (HR: 2.13 [95% CI: 0.86-5.29]; p=0.102). Moderate exacerbations did not significantly increase the risk of ACM during or after an exacerbation. Cardiopulmonary composite events occurred in 647 (16%), 636 (15%), and 356 (17%) patients receiving FF/UMEC/VI, FF/VI, and UMEC/VI, respectively; FF/UMEC/VI significantly reduced cardiopulmonary composite event risk versus UMEC/VI by 16.5% (95% CI: 5.0-26.7; p=0.006). Conclusion Results confirm a substantial mortality risk during severe exacerbations, and an underlying CV risk. FF/UMEC/VI significantly reduced the risk of a composite cardiopulmonary AE versus UMEC/VI.
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Affiliation(s)
- J Michael Wells
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States
| | - David M G Halpin
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - MeiLan K Han
- Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan, United States
| | - Renu Jain
- GSK, Research Triangle Park, North Carolina, United States
| | - Peter Lange
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Pulmonary Section, Medical Department, Herlev-Gentofte Hospital, Herlev, Denmark
| | - David A Lipson
- GSK, Collegeville, Pennsylvania, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Fernando J Martinez
- New York-Presbyterian Weill Cornell Medical Center, New York, New York, United States
| | | | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Foundation Hospital Trust, Manchester, United Kingdom
| | - Robert A Wise
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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Dransfield MT, Criner GJ, Halpin DMG, Han MK, Hartley B, Kalhan R, Lange P, Lipson DA, Martinez FJ, Midwinter D, Singh D, Wise R, Kunisaki KM. Time‐Dependent Risk of Cardiovascular Events Following an Exacerbation in Patients With Chronic Obstructive Pulmonary Disease: Post Hoc Analysis From the IMPACT Trial. J Am Heart Assoc 2022; 11:e024350. [PMID: 36102236 PMCID: PMC9683674 DOI: 10.1161/jaha.121.024350] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background The association between chronic obstructive pulmonary disease exacerbations and increased cardiovascular event risk has not been adequately studied in a heterogenous population with both low and high cardiovascular risk. Methods and Results This post hoc analysis of the IMPACT (Informing the Pathway of COPD Treatment) trial (N=10 355 symptomatic patients with chronic obstructive pulmonary disease at risk of exacerbations) evaluated time‐dependent risk of cardiovascular adverse events of special interest (CVAESI) following exacerbations and impact of exacerbation history, cardiovascular risk factors, and study treatment on this association. Risk (time‐to‐first) of CVAESI or CVAESI resulting in hospitalization or death was assessed during and 1 to 30, 31 to 90, and 91 to 365 days after resolution of moderate or severe exacerbations. CVAESI risk was compared between the period before and during/after exacerbation. CVAESI risk increased significantly during a moderate (hazard ratio [HR], 2.63 [95% CI, 2.08–3.32]) or severe (HR, 21.84 [95% CI, 17.71–26.93]) exacerbation and remained elevated for 30 days following an exacerbation (moderate: HR, 1.63 [95% CI, 1.28–2.08]; severe: HR, 1.75 [95% CI, 0.99–3.11; nonsignificant]) and decreased over time, returning to baseline by 90 days. Risk of CVAESI resulting in hospitalization or death also increased during an exacerbation (moderate: HR, 2.46 [95% CI, 1.53–3.97]; severe: HR, 41.29 [95% CI, 30.43–56.03]) and decreased in a similar time‐dependent pattern. Results were consistent regardless of exacerbation history, cardiovascular risk at screening, or study treatment. Conclusions Overall risk of cardiovascular events was higher during and in the 30 days following chronic obstructive pulmonary disease exacerbations, even among those with low cardiovascular risk, highlighting the need for exacerbation prevention and vigilance for cardiovascular events following exacerbations. Registration URL: https://clinicaltrials.gov/ct2/show/NCT02164513; Unique identifier: NCT02164513
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Affiliation(s)
| | - Gerard J. Criner
- Lewis Katz School of Medicine at Temple University Philadelphia PA
| | - David M. G. Halpin
- University of Exeter Medical School University of Exeter Exeter United Kingdom
| | | | | | - Ravi Kalhan
- Division of Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Peter Lange
- University of Copenhagen Denmark
- Herlev‐Gentofte Hospital Herlev Denmark
| | - David A. Lipson
- GSK Collegeville PA
- Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | | | | | - Dave Singh
- Centre for Respiratory Medicine and Allergy Institute of Inflammation and Repair Manchester Academic Health Science Centre The University of Manchester Manchester University NHS Foundation Hospital Trust Manchester United Kingdom
| | - Robert Wise
- Johns Hopkins University School of Medicine Baltimore MD
| | - Ken M. Kunisaki
- Minneapolis Veterans Affairs Health Care System University of Minnesota Twin Cities Medical School Minneapolis MN
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Cazzola M, Rogliani P, Calzetta L, Ora J, Matera MG. A single inhaler triple therapy fluticasone furoate/umeclidinium/vilanterol for the treatment of COPD. Expert Rev Clin Pharmacol 2022; 15:269-283. [PMID: 35475762 DOI: 10.1080/17512433.2022.2071700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Single inhaler triple therapy (SITT) with an inhaled corticosteroid, a long-acting β2-agonist, and a long-acting muscarinic antagonist is an effective and attractive therapeutic option codified in the recommendations of guidelines and treatment strategies for the management of COPD. AREAS COVERED : The preclinical and clinical development in COPD of fluticasone furoate (FF)/umeclidinium (UMEC)/vilanterol (VI) SITT and its use in the real world. EXPERT OPINION : Findings from phase III/IV trials and the use of FF/UMEC/VI in the real-world setting support the view that it may be a useful, safe, and cost-effective option for the maintenance treatment of COPD, especially when dealing with patients who are not adequately controlled with dual ICS/LABA or LAMA/LABA therapy. Only direct head-to-head comparisons will be able to establish whether FF/UMEC/VI may be preferable to the other SITTs approved for COPD due to its pharmacokinetic and pharmacodynamic characteristics and especially the fact that it is the only one that can be taken once-daily. In addition, there is a need for further studies, especially in the real world, to optimize the positioning of FF/UMEC/VI in the treatment of COPD, also considering the availability of FF/VI and UMEC/VI and the need for better differentiation between the three treatments.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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8
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Aguilar-Shea AL, Gallardo-Mayo C. [COPD inhaled therapy narrative review]. Semergen 2021; 48:214-218. [PMID: 34493458 DOI: 10.1016/j.semerg.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
Inhaled therapy with long-acting bronchodilators is the base of pharmacological treatment in COPD. In order to find out those that offer better control, a search was carried out in Medline (Pubmed). Comparative studies of inhaler therapy in COPD patients were analyzed. The comparison between the fixed combination LABA/LAMA versus LABA/CI in non-exacerbating patients, revealed a better control with LABA/LAMA. Within the LABA/CI combinations, budesonide/formoterol combination offered better control. LAMA inhalers revealed no great differences, but when compared to LABA, it offered a better control. Regarding triple therapy in a single device, was superior to double therapy and to triple therapy in two devices, with no relevant differences among the available combinations.
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Affiliation(s)
- A L Aguilar-Shea
- Medicina Familiar y Comunitaria, Centro de Salud Puerta de Madrid, Atención Primaria de Madrid, Madrid, España.
| | - C Gallardo-Mayo
- Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario Infanta Leonor, Madrid, España
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Celi A, Latorre M, Paggiaro P, Pistelli R. Chronic obstructive pulmonary disease: moving from symptom relief to mortality reduction. Ther Adv Chronic Dis 2021; 14:20406223211014028. [PMID: 34035887 PMCID: PMC8127735 DOI: 10.1177/20406223211014028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/07/2021] [Indexed: 01/13/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) has a 3-year mortality rate up to
37%, 2–6 times higher than the general population. We present evidence
supporting pharmacological therapies to improve patient life expectancy,
focusing on inhaled corticosteroids (ICSs) combined with long-acting
bronchodilators (LABDs). A reduction in 3-year all-cause mortality (ACM) has
been shown in patients with severe COPD treated with fluticasone propionate (an
ICS) and salmeterol [long-acting beta-agonist (LABA)], compared with placebo. An
observational study of elderly patients with severe COPD and multiple
comorbidities suggested ICS+LABD reduce ACM compared with LABD monotherapy.
Patients with symptomatic COPD at risk of exacerbations saw a mortality benefit
with the ICS/long-acting muscarinic antagonist (LAMA)/LABA combinations
fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) or
budesonide/glycopyrrolate/formoterol (BUD/GLY/FOR) versus
UMEC/VI or GLY/FOR (LAMA/LABA combinations) in the IMPACT and ETHOS trials,
respectively. Reduced risk of mortality may be due to modulation of airway
inflammation, thereby reducing activation of proinflammatory mediators in the
peripheral circulation. Importantly, estimated annual risk reduction for ACM
with ICS/LAMA/LABA combinations in patients with COPD is of the same order of
magnitude as for statins (patients with coronary disease) and
angiotensin-converting enzyme inhibitors (patients with vascular disease). Based
on the current data, the pharmacological treatment of COPD appears not only able
to improve symptoms and reduce the frequency of exacerbations but is also very
promising in improving patient prognosis in the long term.
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Affiliation(s)
- Alessandro Celi
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Toscana, Italy
| | - Manuela Latorre
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Toscana, Italy
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Toscana, Italy
| | - Riccardo Pistelli
- Catholic University School of Medicine, Largo Francesco Vito 1, Rome, 00168, Italy
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Affiliation(s)
- Luigino Calzetta
- Unit of Respiratory Disease and Lung Function Department Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Unit of Pharmacology, Department Experimental Medicine, Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Unit of Pharmacology, Department Experimental Medicine, Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
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