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Liu MC, Chipps B, Munoz X, Devouassoux G, Bergna M, Smith SG, Price RG, Galkin DV, Azmi J, Mouneimne D, Albers FC, Chapman KR. Benefit of switching to mepolizumab from omalizumab in severe eosinophilic asthma based on patient characteristics. Respir Res 2021; 22:144. [PMID: 33971856 PMCID: PMC8111733 DOI: 10.1186/s12931-021-01733-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 02/25/2021] [Accepted: 04/25/2021] [Indexed: 12/18/2022] Open
Abstract
Background The OSMO study assessed the efficacy of switching to mepolizumab in patients with severe eosinophilic asthma that was uncontrolled whilst receiving omalizumab. The objective of this analysis was to assess the proportion of patients achieving pre-defined improvements in up to four efficacy outcomes and the relationship between patient baseline characteristics and treatment response. Methods This was a post hoc analysis of OSMO study data (GSK ID:204471; ClinicalTrials.gov No. NCT02654145). Patients with severe eosinophilic asthma uncontrolled by high-dose inhaled corticosteroids, other controller(s) and omalizumab subcutaneously (≥ 4 months) were switched to mepolizumab 100 mg administered subcutaneously. Endpoints included the proportion of responders—i.e. patients achieving a pre-defined clinical improvement in ≥ 1 of the following outcomes: (1) Asthma Control Questionnaire (ACQ)-5 score (≥ 0.5-points), (2) St George’s Respiratory Questionnaire (SGRQ) total score (≥ 4-points), (3) pre-bronchodilator forced expiratory volume in 1s (FEV1; ≥ 100 mL), all at Week 32, and (4) annualised rate of clinically significant exacerbations (≥ 50% reduction). Results Of the 145 patients included, 94%, 83%, 63% and 31% were responders for ≥ 1, ≥ 2, ≥ 3 and 4 outcomes, respectively; 75% and 78% were ACQ-5 and SGRQ score responders, and 50% and 69% were FEV1 and exacerbation responders. Subgroup analyses demonstrated improvements irrespective of baseline blood eosinophil count, prior omalizumab treatment regimen/duration, comorbidities, prior exacerbation history, maintenance oral corticosteroid use, ACQ-5 and SGRQ scores, and body weight/body mass index. Conclusions After switching to mepolizumab, almost all patients with uncontrolled severe eosinophilic asthma on omalizumab achieved a beneficial response in ≥ 1 clinical outcome. Improvements were observed regardless of baseline characteristics. Trial registration This manuscript is a post hoc analysis of data from the OSMO study. ClinicalTrials.gov, NCT02654145. Registered January 13, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01733-9.
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Affiliation(s)
- Mark C Liu
- Divisions of Allergy and Clinical Immunology, Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, Baltimore, MD, USA
| | - Bradley Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, CA, USA
| | - Xavier Munoz
- Pulmonology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias, Madrid, Spain
| | - Gilles Devouassoux
- Service de Pneumologie, Hôpital de la Croix Rousse, Hospices Civils de Lyon, UCB Lyon, Lyon, France
| | - Miguel Bergna
- Respiratory Research, CEMER, Vicente Lopez, Buenos Aires, Argentina
| | - Steven G Smith
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA
| | | | - Dmitry V Galkin
- Global Respiratory Medical Franchise, GSK, Research Triangle Park, NC, USA.,Chiesi USA, Cary, NC, USA
| | - Jay Azmi
- Respiratory TAU, GSK, Uxbridge, Middlesex, UK
| | | | - Frank C Albers
- Global Respiratory Medical Franchise, GSK, Research Triangle Park, NC, USA.,Avillion US Inc, Northbrook, IL, USA
| | - Kenneth R Chapman
- Asthma and Airway Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
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Müllerová H, Meeraus WH, Galkin DV, Albers FC, Landis SH. Clinical burden of illness among patients with severe eosinophilic COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:741-755. [PMID: 31114180 PMCID: PMC6497493 DOI: 10.2147/copd.s194511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/11/2019] [Indexed: 11/29/2022] Open
Abstract
Background: There are currently limited real-world data on the clinical burden of illness in patients with COPD who continue to exacerbate despite receiving triple therapy. The aim of this study was to compare the burden of COPD in patients with and without a phenotype characterized by a high blood eosinophil count and high risk of exacerbations while receiving triple therapy. Methods: This retrospective cohort study (GSK ID: 207323/PRJ2647) used UK Clinical Practice Research Datalink records linked with Hospital Episode Statistics. Eligible patients had a COPD medical diagnosis code recorded between January 1, 2004 and December 31, 2014, and a blood eosinophil count recorded on/after that date. Patients were followed from index date (first qualifying blood eosinophil count) until December 31, 2015. The study phenotype was defined as ≥2 moderate/≥1 severe acute exacerbation of COPD (AECOPD) in the year prior to the index date, current use of multiple-inhaler triple therapy (MITT), and blood eosinophil count ≥150 cells/µL on the index date. Outcomes measured during follow-up included moderate/severe AECOPDs, severe AECOPDs, all-cause mortality, primary care (GP) clinical consultations, and non-AECOPD-related unscheduled hospitalizations. Results: Of 46,814 patients eligible for inclusion, 2512 (5.4%) met the definition of the study phenotype. Adjusted rate ratios (95% CI) of moderate/severe AECOPDs and all-cause mortality in patients with the study phenotype versus those without were 2.32 (2.22, 2.43) and 1.26 (1.16, 1.37), respectively. For GP visits and non-AECOPD-related unscheduled hospitalizations, adjusted rate ratios (95% CI), in patients with the study phenotype versus those without, were 1.09 (1.05, 1.12) and 1.31 (1.18, 1.46), respectively. Conclusion: Patients with COPD and raised blood eosinophil counts who continue to exacerbate despite MITT represent a distinct subgroup who experience substantial clinical burden and account for high healthcare expenditure. There is a need for more effective management and therapeutic options for these patients.
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Affiliation(s)
| | | | | | | | - Sarah H Landis
- Respiratory Epidemiology, GSK, Uxbridge, UK.,Patient Centered Outcomes and Value Evidence and Outcomes, GSK, Collegeville, PA, USA
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Feldman GJ, Galkin DV, Patel P, Collison KA, Sharma R. Correct use and ease of use of a placebo dry powder inhaler in subjects with asthma and chronic obstructive pulmonary disease. Chron Respir Dis 2019; 16:1479973118815692. [PMID: 30789018 PMCID: PMC6302980 DOI: 10.1177/1479973118815692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/18/2018] [Indexed: 11/18/2022] Open
Abstract
Correct use and ease of use of a placebo dry powder inhaler was evaluated in two single-arm, United States-multicenter, phase-IV studies in adults with asthma ( n = 259) or chronic obstructive pulmonary disease (COPD; n = 278) who were receiving maintenance inhaler therapy. Subjects demonstrating correct placebo inhaler use within three attempts at screening were instructed to take once-daily inhalations from the inhaler for 28 ± 2 days (continuing usual maintenance), followed by randomization to complete one of two versions of an ease-of-use questionnaire and reassessment for correct inhaler use. At study end, 96% asthma/93% COPD subjects rated the placebo inhaler as "easy" or "very easy" to use while demonstrating correct use. Furthermore, 99% asthma/99% COPD subjects indicated it was "easy" or "very easy" to determine number of doses remaining, and 81%/84%, respectively, indicated they would be "likely" or "very likely" to request their current medication in the inhaler, if available. Adverse event (AE) rates were 12% asthma/15% COPD, most frequently headache (3%/3%). Treatment-related AEs were reported in one subject with asthma (cough) and four subjects with COPD (cough, n = 3; back pain, n = 1). At study end, most subjects with asthma or COPD operated the placebo inhaler correctly and found it easy to use.
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Affiliation(s)
| | - Dmitry V Galkin
- Respiratory Medical Franchise, GlaxoSmithKline, Durham, NC, USA
| | - Pinal Patel
- Respiratory Therapy Area Unit, GlaxoSmithKline, Uxbridge, UK
| | | | - Raj Sharma
- Respiratory Medical Franchise, GlaxoSmithKline, Brentford, UK
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Rubin DB, Ahmad HA, O'Neal M, Bennett S, Lettis S, Galkin DV, Crim C. Predictors of pneumonia on routine chest radiographs in patients with COPD: a post hoc analysis of two 1-year randomized controlled trials. Int J Chron Obstruct Pulmon Dis 2018; 13:189-201. [PMID: 29386888 PMCID: PMC5764287 DOI: 10.2147/copd.s142530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Patients with COPD are at risk for life-threatening pneumonia. Although anatomical abnormalities in the thorax may predispose to pneumonia, those abnormalities identified on routine chest X-rays (CXRs) in patients with COPD have not been studied to better understand pneumonia risk. Methods We conducted a post hoc exploratory analysis of data from two replicate year-long clinical trials assessing the impact of fluticasone furoate–vilanterol versus vilanterol alone on COPD exacerbations (GSK studies: HZC102871/NCT01009463 and HZC102970/NCT01017952). Abnormalities on baseline CXRs from 179 patients who developed pneumonia and 50 randomly selected patients who did not were identified by blinded consensus readings conducted by two radiologists. Positive and negative likelihood ratios and diagnostic odds ratios (ORs) were calculated to evaluate the markers for subsequent pneumonia development during the 1-year study period. Results Baseline characteristics distinguishing the pneumonia and non-pneumonia groups included a lower body mass index (24.9 vs 27.5 kg/m2, P=0.008), more severe airflow obstruction (mean post-bronchodilator forced expiratory volume in 1 second [FEV1]/forced vital capacity ratio: 42.3% vs 47.6%, P=0.003), and prior pneumonia (36% vs 20%, P=0.030). Baseline CXR findings with the highest diagnostic ORs were: elevated hemi-diaphragm (OR: 6.87; 95% CI: 0.90, 52.26), thick tracheal-esophageal stripe (OR: 4.39 [0.25, 78.22]), narrow cardiac silhouette (OR: 2.91 [0.85, 9.99]), calcified pleural plaque/mid-chest pleural thickening (OR: 2.82 [0.15, 53.76]), and large/prominent pulmonary artery shadow (OR: 1.94 [0.95, 3.97]). The presence of a narrow cardiac silhouette at baseline was associated with a statistically significant lower mean pre-bronchodilator FEV1 (P=0.040). There was also a trend for a lower mean pre-bronchodilator FEV1 in patients with a large/prominent pulmonary artery shadow at baseline (P=0.095). Conclusion Findings on routine CXR that relate to pathophysiological mechanisms of pneumonia could help determine pneumonia risk in patients with COPD.
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Affiliation(s)
| | - Harris A Ahmad
- Medical Affairs, Medical Imaging and Biomarkers, BioClinica Inc., Princeton, NJ, USA
| | - Michael O'Neal
- Medical Affairs, Medical Imaging and Biomarkers, BioClinica Inc., Princeton, NJ, USA
| | - Sophie Bennett
- Statistics and Programming, GSK, Stockley Park, Uxbridge, UK
| | - Sally Lettis
- Statistics and Programming, GSK, Stockley Park, Uxbridge, UK
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Kerwin EM, Kalberg CJ, Galkin DV, Zhu CQ, Church A, Riley JH, Fahy WA. Umeclidinium/vilanterol as step-up therapy from tiotropium in patients with moderate COPD: a randomized, parallel-group, 12-week study. Int J Chron Obstruct Pulmon Dis 2017; 12:745-755. [PMID: 28280319 PMCID: PMC5338844 DOI: 10.2147/copd.s119032] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Patients with COPD who remain symptomatic on long-acting bronchodilator monotherapy may benefit from step-up therapy to a long-acting bronchodilator combination. This study evaluated the efficacy and safety of umeclidinium (UMEC)/vilanterol (VI) in patients with moderate COPD who remained symptomatic on tiotropium (TIO). Methods In this randomized, blinded, double-dummy, parallel-group study (NCT01899742), patients (N=494) who were prescribed TIO for ≥3 months at screening (forced expiratory volume in 1 s [FEV1]: 50%–70% of predicted; modified Medical Research Council [mMRC] score ≥1) and completed a 4-week run-in with TIO were randomized to UMEC/VI 62.5/25 µg or TIO 18 µg for 12 weeks. Efficacy assessments included trough FEV1 at Day 85 (primary end point), 0–3 h serial FEV1, rescue medication use, Transition Dyspnea Index (TDI), St George’s Respiratory Questionnaire (SGRQ), and COPD Assessment Test (CAT). Safety evaluations included adverse events (AEs). Results Compared with TIO, UMEC/VI produced greater improvements in trough FEV1 (least squares [LS] mean difference: 88 mL at Day 85 [95% confidence interval {CI}: 45–131]; P<0.001) and FEV1 after 5 min on Day 1 (50 mL [95% CI: 27–72]; P<0.001). Reductions in rescue medication use over 12 weeks were greater with UMEC/VI versus TIO (LS mean change: −0.1 puffs/d [95% CI: −0.2–0.0]; P≤0.05). More patients achieved clinically meaningful improvements in TDI score (≥1 unit) with UMEC/VI (63%) versus TIO (49%; odds ratio at Day 84=1.78 [95% CI: 1.21–2.64]; P≤0.01). Improvements in SGRQ and CAT scores were similar between treatments. The incidence of AEs was similar with UMEC/VI (30%) and TIO (31%). Conclusion UMEC/VI step-up therapy provides clinical benefit over TIO monotherapy in patients with moderate COPD who are symptomatic on TIO alone.
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Affiliation(s)
| | - Chris J Kalberg
- Respiratory Department, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Dmitry V Galkin
- Respiratory Department, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Chang-Qing Zhu
- Clinical Statistics, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex
| | - Alison Church
- Respiratory Department, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - John H Riley
- Respiratory Department, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex, UK
| | - William A Fahy
- Respiratory Department, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex, UK
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Chuchalin AG, Khaltaev N, Antonov NS, Galkin DV, Manakov LG, Antonini P, Murphy M, Solodovnikov AG, Bousquet J, Pereira MHS, Demko IV. Chronic respiratory diseases and risk factors in 12 regions of the Russian Federation. Int J Chron Obstruct Pulmon Dis 2014; 9:963-74. [PMID: 25246783 PMCID: PMC4166963 DOI: 10.2147/copd.s67283] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Estimation suggests that at least 4 million people die, annually, as a result of chronic respiratory disease (CRD). The Global Alliance against Chronic Respiratory Diseases (GARD) was formed following a mandate from the World Health Assembly to address this serious and growing health problem. OBJECTIVES To investigate the prevalence of CRD in Russian symptomatic patients and to evaluate the frequency of major risk factors for CRD in Russia. METHODS A cross-sectional, population-based epidemiological study using the GARD questionnaire on adults from 12 regions of the Russian Federation. Common respiratory symptoms and risk factors were recorded. Spirometry was performed in respondents with suspected CRD. Allergic rhinitis (AR) and chronic bronchitis (CB) were defined by the presence of related symptoms according to the Allergic Rhinitis and its Impact on Asthma and the Global Initiative for Obstructive Lung Disease guidelines; asthma was defined based on disease symptoms; chronic obstructive pulmonary disease (COPD) was defined as a post-bronchodilator forced expiratory volume per 1 second/forced vital capacity ratio <0.7 in symptomatic patients, following the Global Initiative for Obstructive Lung Disease guidelines. RESULTS The number of questionnaires completed was 7,164 (mean age 43.4 years; 57.2% female). The prevalence of asthma symptoms was 25.7%, AR 18.2%, and CB 8.6%. Based on patient self-reported diagnosis, 6.9% had asthma, 6.5% AR, and 22.2% CB. The prevalence of COPD based on spirometry in patients with respiratory symptoms was estimated as 21.8%. CONCLUSION The prevalence of respiratory diseases and risk factors was high in Russia when compared to available data. For bronchial asthma and AR, the prevalence for related symptoms was higher than self-reported previous diagnosis.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Bronchitis, Chronic/diagnosis
- Bronchitis, Chronic/epidemiology
- Bronchitis, Chronic/physiopathology
- Cross-Sectional Studies
- Female
- Forced Expiratory Volume
- Health Surveys
- Humans
- Lung/physiopathology
- Male
- Middle Aged
- Prevalence
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/epidemiology
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Rhinitis, Allergic/diagnosis
- Rhinitis, Allergic/epidemiology
- Rhinitis, Allergic/physiopathology
- Risk Factors
- Russia/epidemiology
- Spirometry
- Surveys and Questionnaires
- Vital Capacity
- Young Adult
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Affiliation(s)
| | - Nikolai Khaltaev
- Global Alliance Against Chronic Respiratory Diseases (GARD), Genève, Switzerland
| | - Nikolay S Antonov
- Institute of Pulmonology, Federal Medical and Biological Agency, Moscow, Russia
| | | | - Leonid G Manakov
- Far Eastern Scientific Center of Physiology and Pathology of Respiration RAS (Russian Academy of Sciences), Blagoveshchensk, Russia
| | | | | | | | - Jean Bousquet
- Institut National de la Santé et de la Recherche Médicale, Montpellier, France
| | - Marcelo HS Pereira
- Research and Development Chief Medical Office, International Medical, GlaxoSmithKline, London, United Kingdom
| | - Irina V Demko
- Krasnoyarsk State Medical University, Krasnoyarsk, Russia
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DiSantostefano RL, Li H, Hinds D, Galkin DV, Rubin DB. Risk of pneumonia with inhaled corticosteroid/long-acting β2 agonist therapy in chronic obstructive pulmonary disease: a cluster analysis. Int J Chron Obstruct Pulmon Dis 2014; 9:457-68. [PMID: 24855350 PMCID: PMC4019612 DOI: 10.2147/copd.s60498] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pneumonia poses a significant risk in patients with moderate to severe chronic obstructive pulmonary disease but data are limited on the disease phenotypes most susceptible to pneumonia. Methods Cluster analysis using a data-driven recursive partitioning algorithm was employed using baseline data from two pooled one-year randomized exacerbation trials (n=3,255) of fluticasone furoate/vilanterol or vilanterol alone to identify distinct patient groups at greatest risk of pneumonia or serious (hospitalization or death) pneumonia. Results Five clusters were identified. Patients at greater risk of first pneumonia had more severe obstruction (forced expiratory volume in one second/forced vital capacity <46%) and either a body mass index <19 kg/m2 (hazard ratio 7.8, 95% confidence interval 4.7–13.0; n=144) or a pneumonia history and greater comorbidities (hazard ratio 4.8, 95% confidence interval 3.0–7.7; n=374) relative to the cluster with the lowest pneumonia risk (reference; n=1310). Multiple comorbidities and use of psychoanaleptics also contributed to an increased risk of pneumonia in more obstructed patients. Independent of cluster, use of inhaled corticosteroids was associated with pneumonia (hazard ratio 1.89, 95% confidence interval 1.25–2.84) and serious pneumonia (hazard ratio 2.92, 95% confidence interval 1.40–6.01). Conclusion Cluster analysis can identify patient populations at risk for serious safety outcomes and inform risk management strategies to optimize patient management. The greatest risk for pneumonia was in subjects with multiple pneumonia risk factors.
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Affiliation(s)
| | - Hao Li
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
| | - David Hinds
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
| | - Dmitry V Galkin
- Respiratory Clinical Development, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
| | - David B Rubin
- Respiratory Clinical Development, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
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Stratchounski LS, Andreeva IV, Ratchina SA, Galkin DV, Petrotchenkova NA, Demin AA, Kuzin VB, Kusnetsova ST, Likhatcheva RY, Nedogoda SV, Ortenberg EA, Belikov AS, Toropova IA. The inventory of antibiotics in Russian home medicine cabinets. Clin Infect Dis 2003; 37:498-505. [PMID: 12905133 DOI: 10.1086/376905] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2002] [Accepted: 04/04/2003] [Indexed: 11/03/2022] Open
Abstract
The objective of this study was to inventory the stock of antimicrobials in the home medicine cabinets (HMCs) of the general population in Russia and to find out for which indications people report that they would use antibiotics without a physician's recommendation. The research was performed in 9 Russian cities by physicians who visited households. An inventory of antibiotics in HMCs was made, and respondents were asked about instances in which they would choose automedication with antibiotics. We found that 83.6% of families had antibiotics for systemic use in HMCs. The most common antibiotics in HMCs were trimethoprim-sulfamethoxazole (46.3% of HMCs), ampicillin (45.1%), chloramphenicol (32.7%), erythromycin (25.5%), and tetracycline (21.8%). The major indications for automedication with antibiotics were acute viral respiratory tract infections (12.3% of total indications), cough (11.8%), intestinal disorders (11.3%), fever (9%), and sore throat (6.8%). According to this study, antibiotics are widely stocked among the general population in Russia, and people use antibiotics in an uncontrolled and imprudent manner.
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Affiliation(s)
- L S Stratchounski
- Institute of Antimicrobial Chemotherapy, Smolensk State Medical Academy, Smolensk, Russia.
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