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Huang J, Moss A, Hoyt BM, Watson JD, Brittan MS. Factors Associated with Inhaled Bronchodilator and Oral Corticosteroid Use in Young Children with First Lower Respiratory Tract Infection. J Pediatr 2024; 267:113912. [PMID: 38244887 DOI: 10.1016/j.jpeds.2024.113912] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/16/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES To examine factors associated with claims for and potential overuse of inhaled bronchodilators (IBs) and oral corticosteroids (OCSs) for children <2 years old at first lower respiratory tract infections (LRTIs). STUDY DESIGN Retrospective cohort study using Colorado All Payer Claims data from 2009 through 2019. Children with asthma were excluded. Primary outcomes were 1) IB and 2) OCS claims within 7 days of index LRTI. Primary predictors were previous IB or OCS claims for each outcome respectively. Covariates included demographics, atopy, family history of asthma, complex chronic conditions, prior inhaled corticosteroid claim, and location of index LRTI. Separate multivariable logistic regression models were used for each outcome. RESULTS Of 10 194 eligible children, 1468 (14.4%) had an IB and 741 (7.3%) an OCS claim at or within 7 days of index LRTI. Index LRTIs were most often at outpatient visits (64%). Adjusting for covariates, prior IB prescription was associated with the IB outcome (aOR 1.9; 95% CI 1.3, 2.8), and prior OCS prescription was associated with the OCS outcome (AOR 2.2; 95% CI 1.7, 2.9). Other variables associated with either outcome included age, sex, insurance, location, and atopy. Prior inhaled corticosteroid claim, asthma family history, and complex chronic conditions were not associated with either outcome. CONCLUSIONS This study identifies factors that might serve as opportunities for de-implementation strategies for IB and OCS overuse in young children with LRTI.
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Affiliation(s)
- Joy Huang
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
| | - Angela Moss
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO
| | - Brandy M Hoyt
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - John D Watson
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mark S Brittan
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO
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Hardee IJ, Zaniletti I, Tanverdi MS, Liu AH, Mistry RD, Navanandan N. Emergency management and asthma risk in young Medicaid-enrolled children with recurrent wheeze. J Asthma 2024:1-8. [PMID: 38324665 DOI: 10.1080/02770903.2024.2314623] [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: 08/03/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVES To describe clinical characteristics of young children presenting to the emergency department (ED) for early recurrent wheeze, and determine factors associated with subsequent persistent wheeze and risk for early childhood asthma. METHODS Retrospective cohort study of Medicaid-enrolled children 0-3 years old with an index ED visit for wheeze (e.g. bronchiolitis, reactive airway disease) from 2009 to 2013, and at least one prior documented episode of wheeze at an ED or primary care visit. The primary outcome was persistent wheeze between 4 and 6 years of age. Demographics and clinical characteristics were collected from the index ED visit. Logistic regression was used to estimate the association between potential risk factors and subsequent persistent wheeze. RESULTS During the study period, 41,710 children presented to the ED for recurrent wheeze. Mean age was 1.3 years; 59% were male, 42% Black, and 6% Hispanic. At index ED visits, the most common diagnosis was acute bronchiolitis (40%); 77% of children received an oral corticosteroid prescription. Between 4 and 6 years of age, 11,708 (28%) children had persistent wheeze. A greater number of wheezing episodes was associated with an increased odds of ED treatment with asthma medications. Subsequent persistent wheeze was associated with male sex, Black race, atopy, prescription for bronchodilators or corticosteroids, and greater number of visits for wheeze. CONCLUSIONS Young children with persistent wheeze are at risk for childhood asthma. Thus, identification of risk factors associated with persistent wheeze in young children with recurrent wheeze might aid in early detection of asthma and initiation of preventative therapies.
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Affiliation(s)
- Isabel J Hardee
- Department of Pediatrics, University of CO School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Melisa S Tanverdi
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Andrew H Liu
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Nidhya Navanandan
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Course CW, Kotecha SJ, Kotecha S. Evolving treatment for prematurity-associated lung disease. Transl Pediatr 2024; 13:1-5. [PMID: 38323186 PMCID: PMC10839272 DOI: 10.21037/tp-23-505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/18/2023] [Indexed: 02/08/2024] Open
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Su VYF, Ding TL, Chang YL, Chou YC, Hwang HE, Chou CY, Hsu CC. Comparative effectiveness and safety of inhaled corticosteroid plus long-acting β 2-agonist fixed-dose combinations vs. long-acting muscarinic antagonist in bronchiectasis. Expert Rev Clin Pharmacol 2024; 17:157-164. [PMID: 38224017 DOI: 10.1080/17512433.2024.2306218] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/12/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND This study aimed to evaluate the effectiveness and safety of fixed-dose combination (FDC) inhaled corticosteroids/long-acting β2-agonists (ICS/LABA) in bronchiectasis. RESEARCH DESIGN AND METHODS A retrospective cohort study analyzed electronic medical records of bronchiectasis patients initiating ICS/LABA FDC or LAMA between 2007 and 2021. All bronchiectasis diagnoses were made by radiologists using high-resolution computed tomography. RESULTS Of the 1,736 patients, 1,281 took ICS/LABA FDC and 455 LAMA. Among the 694 propensity score matched patients, ICS/LABA FDC had comparable outcomes to LAMA, with HRs of 1.22 (95% CI 0.81-1.83) for hospitalized respiratory infection, 1.06 (95% CI 0.84-1.33) for acute exacerbation, and 1.06 (95% CI 0.66-1.02) for all-cause hospitalization. Beclomethasone/formoterol (BEC/FOR) or budesonide/formoterol (BUD/FOR) led to a lower risk of acute exacerbation compared to fluticasone/salmeterol (FLU/SAL) (BEC/FOR HR 0.59, 95% CI 0.43-0.81; BUD/FOR HR 0.68, 95% CI 0.50-0.93). BEC/FOR resulted in lower risks of hospitalized respiratory infection (HR 0.48, 95% 0.26-0.86) and all-cause hospitalization (HR 0.55, 95% 0.37-0.80) compared to FLU/SAL. CONCLUSION Our findings provide important evidence on the effectiveness and safety of ICS/LABA FDC compared with LAMA for bronchiectasis. BEC/FOR and BUD/FOR were associated with better outcomes than FLU/SAL.
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Affiliation(s)
- Vincent Yi-Fong Su
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Internal Medicine, Taipei City Hospital, Taipei City Government, Taipei, Taiwan
- Department of Exercise and Health Sciences, College of Kinesiology, University of Taipei, Taipei, Taiwan
| | - Ting-Lin Ding
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yueh-Ching Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsuen-En Hwang
- Department of Internal Medicine, Taipei City Hospital, Taipei City Government, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chian-Ying Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Chaoui M, Fischer E, Perinel-Ragey S, Prévôt N, Leclerc L, Pourchez J. Development of a Novel Bronchodilator Vaping Drug Delivery System Based on Thermal Degradation Properties. Pharmaceuticals (Basel) 2023; 16:1730. [PMID: 38139856 PMCID: PMC10747077 DOI: 10.3390/ph16121730] [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: 10/12/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
This work aims to investigate bronchodilator delivery with the use of different vaping drug delivery systems (VDDS) by determining the dose equivalence delivered in relation to different references: a clinical jet nebulizer, a pMDI (pressurized metered dose inhaler) and a DPI (dry powder inhaler). Three different bronchodilators were used (terbutaline, salbutamol hemisulfate, ipratropium bromide). The e-liquids contained the active pharmaceutical ingredient (API) in powder form. Two different VDDS were tested (JUUL and a GS AIR 2 atomizer paired with a variable lithium-ion battery (i-stick TC 40 W), 1.5 ohm resistance, and 15 W power). Samples were collected using a glass twin impinger (GTI). High-performance liquid chromatography (HPLC) was used to quantify the drugs. A next-generation impactor (NGI) was used to measure the particle size distribution. Terbutaline emerged as the optimal API for bronchodilator delivery in both VDDS devices. It achieved the delivery of a respirable dose of 20.05 ± 4.2 µg/puff for GS AIR 2 and 2.98 ± 0.52 µg/puff for JUUL. With these delivered doses, it is possible to achieve a dose equivalence similar to that of a jet nebulizer and DPI, all while maintaining a reasonable duration, particularly with the GS AIR 2. This study is the first to provide evidence that vaping bronchodilators work only with appropriate formulation, vaping technology, and specific drugs, depending on their thermal degradation properties.
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Affiliation(s)
- Mariam Chaoui
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France; (M.C.); (E.F.); (S.P.-R.); (N.P.); (L.L.)
| | - Emmanuelle Fischer
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France; (M.C.); (E.F.); (S.P.-R.); (N.P.); (L.L.)
| | - Sophie Perinel-Ragey
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France; (M.C.); (E.F.); (S.P.-R.); (N.P.); (L.L.)
- Medical-Surgical Intensive Care Unit, CHU Saint-Etienne, F-42055 Saint-Etienne, France
| | - Nathalie Prévôt
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France; (M.C.); (E.F.); (S.P.-R.); (N.P.); (L.L.)
- Nuclear Medicine Unit, CHU Saint-Etienne, F-42055 Saint-Etienne, France
| | - Lara Leclerc
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France; (M.C.); (E.F.); (S.P.-R.); (N.P.); (L.L.)
| | - Jérémie Pourchez
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France; (M.C.); (E.F.); (S.P.-R.); (N.P.); (L.L.)
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Mangold V, Boesing M, Berset C, Bridevaux PO, Geiser T, Joos Zellweger L, Kohler M, Lüthi-Corridori G, Maier S, Miedinger D, Thurnheer R, von Garnier C, Leuppi JD. Adherence to the GOLD Guidelines in Primary Care: Data from the Swiss COPD Cohort. J Clin Med 2023; 12:6636. [PMID: 37892775 PMCID: PMC10607923 DOI: 10.3390/jcm12206636] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/11/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Introduction: Chronic obstructive pulmonary disease (COPD) and its associated morbidity and mortality are a global burden on both affected patients and healthcare systems. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) issues guidelines with the aim of improving COPD management. Previous studies reported significant variability in adherence to these recommendations. The objective of this study was to evaluate Swiss primary practitioners' adherence to the GOLD guidelines for the pharmacological treatment of stable COPD. (2) Methods: We studied patients who were included in the Swiss COPD cohort study, an ongoing prospective study in a primary care setting, between 2015 and 2022. The key inclusion criteria are age ≥ 40 years, FEV1/FVC ratio < 70%, and a smoking history of at least 20 pack-years. Adherence to the GOLD guidelines was assessed per visit and over time. (3) Results: The data of 225 COPD patients (mean age 67 ± 9 years, 64% male) and their respective 1163 visits were analyzed. In 65% of visits (726/1121), treatment was prescribed according to the GOLD guidelines. Non-adherence was most common in GOLD groups A and B (64% and 33%) and mainly consisted of over-treatment (two long-acting bronchodilators in group A (98/195, 50%) and ICS in groups A (21/195, 11%) and B (198/808, 25%)). In group D, the prescriptions conformed with the guidelines in 99% of cases (109/108). Guideline adherence was associated with high symptom load (COPD Assessment Test) (OR 1.04, p = 0.002), high number of exacerbations (OR = 2.07, p < 0.001), asthma overlap (OR 3.36, p = 0.049), and diabetes mellitus (OR 2.82, p = 0.045). (4) Conclusion: These results confirm a conflict between the GOLD recommendations and primary practice, mainly concerning over-treatment in GOLD groups A and B. Patients with high symptom load, high exacerbation risk, asthma overlap, and diabetes mellitus are more likely to be treated in conformity with the guidelines. Further research is needed to uncover the reasons for the discrepancies and to design strategies for improvement.
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Affiliation(s)
- Veronika Mangold
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Maria Boesing
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Camille Berset
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | | | - Thomas Geiser
- Department of Pulmonary Medicine and Allergology, University Hospital, University of Bern, 3010 Bern, Switzerland
| | | | - Malcolm Kohler
- Department of Pneumology, University Hospital Zürich, 8091 Zürich, Switzerland
| | - Giorgia Lüthi-Corridori
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Sabrina Maier
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
| | - David Miedinger
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Robert Thurnheer
- Clinic of Medicine, Department of Pneumology, Cantonal Hospital Münsterlingen, 8596 Münsterlingen, Switzerland
| | - Christophe von Garnier
- Division of Pulmonology, Department of Medicine, University Hospital Lausanne, CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| | - Jörg Daniel Leuppi
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
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Chipps BE, Israel E, Beasley R, Panettieri RA, Albers FC, Rees R, Dunsire L, Danilewicz A, Johnsson E, Cappelletti C, Papi A. Albuterol-Budesonide Pressurized Metered Dose Inhaler in Patients With Mild-to-Moderate Asthma: Results of the DENALI Double-Blind Randomized Controlled Trial. Chest 2023; 164:585-595. [PMID: 37003355 DOI: 10.1016/j.chest.2023.03.035] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/16/2023] [Accepted: 03/26/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND In the phase 3 MANDALA trial, as-needed albuterol-budesonide pressurized metered-dose inhaler significantly reduced severe exacerbation risk vs as-needed albuterol in patients with moderate-to-severe asthma receiving inhaled corticosteroid-containing maintenance therapy. This study (DENALI) was conducted to address the US Food and Drug Administration combination rule, which requires a combination product to demonstrate that each component contributes to its efficacy. RESEARCH QUESTION Do both albuterol and budesonide contribute to the efficacy of the albuterol-budesonide combination pressurized metered-dose inhaler in patients with asthma? STUDY DESIGN AND METHODS This phase 3 double-blind trial randomized patients aged ≥ 12 years with mild-to-moderate asthma 1:1:1:1:1 to four-times-daily albuterol-budesonide 180/160 μg or 180/80 μg, albuterol 180 μg, budesonide 160 μg, or placebo for 12 weeks. Dual-primary efficacy end points included change from baseline in FEV1 area under the curve from 0 to 6 h (FEV1 AUC0-6h) over 12 weeks (assessing albuterol effect) and trough FEV1 at week 12 (assessing budesonide effect). RESULTS Of 1,001 patients randomized, 989 were ≥ 12 years old and evaluable for efficacy. Change from baseline in FEV1 AUC0-6h over 12 weeks was greater with albuterol-budesonide 180/160 μg vs budesonide 160 μg (least-squares mean [LSM] difference, 80.7 [95% CI, 28.4-132.9] mL; P = .003). Change in trough FEV1 at week 12 was greater with albuterol-budesonide 180/160 and 180/80 μg vs albuterol 180 μg (LSM difference, 132.8 [95% CI, 63.6-201.9] mL and 120.8 [95% CI, 51.5-190.1] mL, respectively; both P < .001). Day 1 time to onset and duration of bronchodilation with albuterol-budesonide were similar to those with albuterol. The albuterol-budesonide adverse event profile was similar to that of the monocomponents. INTERPRETATION Both monocomponents contributed to albuterol-budesonide lung function efficacy. Albuterol-budesonide was well tolerated, even at regular, relatively high daily doses for 12 weeks, with no new safety findings, supporting its use as a novel rescue therapy. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03847896; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
| | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Reynold A Panettieri
- Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, State University of New Jersey, New Brunswick, NJ
| | | | | | - Lynn Dunsire
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | - Eva Johnsson
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Alberto Papi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Bar-Shai A, Freund O, Ovdat T, Segel MJ, Klempfner R, Elis A. Management of acute COPD exacerbations in the internal medicine departments in Israel-a national survey. Front Med (Lausanne) 2023; 10:1174148. [PMID: 37692773 PMCID: PMC10483127 DOI: 10.3389/fmed.2023.1174148] [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: 02/25/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Acute exacerbations of COPD (AECOPD) drastically affect the clinical course of the disease. We aimed to evaluate the treatment of AECOPD in the internal medicine departments in Israel, nationwide. Methods The COPD Israeli survey (COPDIS) is the first national survey of patients admitted with AECOPD to internal medicine departments between 2017 and 2019. The survey includes prospective (n = 344) and retrospective (n = 1,166) data from 13 medical centers. We analyzed the pre-hospital, in-hospital, and pre-discharge care. Hospital evaluation, outcomes and discharge recommendations were assessed as well. Results The mean (±SD) age was 74 (±8) years, and 54% were males. 74% had comorbidities, and 88% had a diagnosis of COPD in their history. 70% of the patients received systemic steroids and antibiotics during their hospitalization, yet upon discharge, a lower rate of antibiotics prescription (10%) was found. Treatment with most long-acting bronchodilators dramatically dropped during admission, compared with their pre-hospital use. Overall, a long-acting bronchodilator (LABD) was used by 47% before admission, 28% in-hospital, and was prescribed to 54% at discharge. The discharge plan included a referral to pulmonary rehabilitation in only 11% and a smoking cessation recommendation in 43% of active smokers. The in-hospital mortality was 3% and the 1-year mortality rate was 25%. In multivariate analysis, performing a chest X-ray (adjusted OR 0.64, 95% CI 0.46-0.90) and prescribing LABD at discharge (AOR 0.73, 95% CI 0.57-0.95) were independent predictors for lower 1-year mortality. Conclusion Our results demonstrate AECOPD characteristics in Israel, and highlight several important gaps in AECOPD healthcare, which must be addressed to improve patient care.
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Affiliation(s)
- Amir Bar-Shai
- The Institute of Pulmonary Medicine, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ophir Freund
- The Institute of Pulmonary Medicine, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Ovdat
- The Israeli Center for Cardiovascular Research (ICCR) and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael J. Segel
- Institute of Pulmonary Medicine, Sheba Tel-Hashomer Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klempfner
- The Israeli Center for Cardiovascular Research (ICCR) and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avishay Elis
- Internal Medicine C, Rabin Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Riney L, Palmer S, Finlay E, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby D, Ostermayer D, Semenova O, Abo BN, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Fishe J. EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval. PREHOSP EMERG CARE 2023; 27:900-907. [PMID: 37428954 PMCID: PMC10592383 DOI: 10.1080/10903127.2023.2234996] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals. METHODS This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics. RESULTS A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min. CONCLUSION In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.
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Affiliation(s)
- Lauren Riney
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | | | | | | | | | - Phyllis Hendry
- University of Florida College of Medicine – Jacksonville
| | - Manish Shah
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - David Ashby
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - Olga Semenova
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | - Benjamin N. Abo
- Lee County Emergency Medical Services, Florida
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Marshall Frank
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Greg Roland
- Nassau County Fire Rescue Department, Florida
| | - Jennifer Fishe
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
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10
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Yu Y, Fang B, Yang XD, Zheng Y. One stone two birds: anti-inflammatory bronchodilators as a potential pharmacological strategy for COVID-19. Front Pharmacol 2023; 14:1185076. [PMID: 37214443 PMCID: PMC10192734 DOI: 10.3389/fphar.2023.1185076] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/21/2023] [Indexed: 05/24/2023] Open
Abstract
The ongoing Coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has imposed a huge threat to public health across the world. While vaccinations are essential for reducing virus transmission and attenuating disease severity, the nature of high mutation rate of SARS-CoV-2 renders vaccines less effective, urging quick development of effective therapies for COVID-19 disease. However, developing novel drugs remains extremely challenging due to the lengthy process and high cost. Alternatively, repurposing of existing drugs on the market represents a rapid and safe strategy for combating COVID-19 pandemic. Bronchodilators are first line drugs for inflammatory lung diseases, such as asthma and chronic obstructive pulmonary disease (COPD). Compared to other anti-inflammatory drugs repurposed for COVID-19, bronchodilators are unique in that they have both anti-inflammatory and bronchodilating properties. Whether the dual properties of bronchodilators empower them greater potential to be repurposed for COVID-19 is worth exploring. In fact, clinical and preclinical studies have recently emerged to investigate the benefits of bronchodilators such assalbutamol, formoterol and theophylline in treating COVID-19, and many of them have shown encouraging efficacy on attenuating disease severity of pneumonia and other associated symptoms. To comprehensively understand the latest progress on COVID-19 intervention with bronchodilators, this review will summarize recent findings in this area and highlight the promising clinical benefits and possible adverse effects of bronchodilators as therapeutic options for COVID-19 with a focus on β2 receptor agonists, anticholinergic drugs and theophylline.
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Affiliation(s)
- Yuanyuan Yu
- The Research Center for Traditional Chinese Medicine, Shanghai Institute of Infectious Diseases and Biosecurity, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Center for Traditional Chinese Medicine and Immunology Research, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bangjiang Fang
- Department of Emergency, LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiao-Dong Yang
- The Research Center for Traditional Chinese Medicine, Shanghai Institute of Infectious Diseases and Biosecurity, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Center for Traditional Chinese Medicine and Immunology Research, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuejuan Zheng
- The Research Center for Traditional Chinese Medicine, Shanghai Institute of Infectious Diseases and Biosecurity, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Center for Traditional Chinese Medicine and Immunology Research, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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11
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Munusamy S, Monfared SSN, Iqbal P, Abdussalam ALM. Challenging case of severe acute asthma in a mechanically ventilated patient managed with sevoflurane. Clin Case Rep 2023; 11:e6571. [PMID: 36846180 PMCID: PMC9949361 DOI: 10.1002/ccr3.6571] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 09/20/2022] [Indexed: 02/27/2023] Open
Abstract
Acute severe bronchial asthma is a chronic inflammatory disease characterized by hyperresponsiveness of the airways leading to bronchoconstriction. We present a case of refractory life-threatening bronchial asthma that was managed with sevoflurane gas along with the standard treatment and achieved stability and clinical improvement through its bronchodilator and anesthetic effect.
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Affiliation(s)
| | | | - Phool Iqbal
- Internal Medicine DepartmentMetropolitan Hospital CenterNew YorkNew YorkUSA
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12
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Calabrese C, Annunziata A, Mariniello DF, Allocca V, Imitazione P, Cauteruccio R, Simioli F, Fiorentino G. Aerosol delivery through high-flow nasal therapy: Technical issues and clinical benefits. Front Med (Lausanne) 2023; 9:1098427. [PMID: 36743674 PMCID: PMC9889634 DOI: 10.3389/fmed.2022.1098427] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/26/2022] [Indexed: 01/20/2023] Open
Abstract
High-flow nasal cannula (HFNC) therapy is an oxygen delivery method particularly used in patients affected by hypoxemic respiratory failure. In comparison with the conventional "low flow" oxygen delivery systems, it showed several important clinical benefits. The possibility to nebulize drugs via HFNC represents a desirable medical practice because it allows the administration of inhaled drugs, mostly bronchodilators, without the interruption or modification of the concomitant oxygen therapy. HFNC, by itself has shown to exert a small but significant bronchodilator effect and improves muco-ciliary clearance; thus, the nebulization of bronchodilators through the HFNC circuit may potentially increase their pharmacological activity. Several technical issues have been observed which include the type of the nebulizer that should be used, its position within the HFNC circuit, and the optimal gas flow rates to ensure an efficient drug delivery to the lungs both in "quiet" and "distressed" breathing patterns. The aim of this review has been to summarize the scientific evidence coming from "in vitro" studies and to discuss the results of "in vivo" studies performed in adult subjects, mainly affected by obstructive lung diseases. Most studies seem to indicate the vibrating mesh nebulizer as the most efficient type of nebulizer and suggest to place it preferentially upstream from the humidifier chamber. In a quite breathing patterns, the inhaled dose seems to increase with lower flow rates while in a "distressed" breathing pattern, the aerosol delivery is higher when gas flow was set below the patient's inspiratory flow, with a plateau effect seen when the gas flow reaches approximately 50% of the inspiratory flow. Although several studies have demonstrated that the percentage of the loaded dose nebulized via HFNC reaching the lungs is small, the bronchodilator effect of albuterol seems not to be impaired when compared to the conventional inhaled delivery methods. This is probably attributed to its pharmacological activity. Prospective and well-designed studies in different cohort of patients are needed to standardize and demonstrate the efficacy of the procedure.
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Affiliation(s)
- Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy,*Correspondence: Cecilia Calabrese,
| | - Anna Annunziata
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | | | - Valentino Allocca
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Pasquale Imitazione
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Rosa Cauteruccio
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Francesca Simioli
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Giuseppe Fiorentino
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
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13
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Awasthi V, Singh S, Kumar N, Kumar M, Sachan AK, Garg R, Kumar R. Evaluation of medical adherence, adverse drug reactions, and quality of life in post tubercular obstructive airway disease. Perspect Clin Res 2023; 14:20-25. [PMID: 36909214 PMCID: PMC10003586 DOI: 10.4103/picr.picr_55_21] [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: 03/10/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background Increasing incidence of tuberculosis is intensifying the posttubercular obstructive airway disease (PTOAD) in developing countries. Currently, there are no standard treatment guidelines for the management of PTOAD patients. The present study aims to evaluate the prescribing pattern, adherence, adverse drug reactions (ADRs), and quality of life (QoL) in PTOAD patients. Materials and Methods A prospective observational study was conducted to evaluate the prescriptions of PTOAD patients, estimating the medical adherence using Morisky 8-Item Medication Adherence Questionnaire, assessing ADRs using Hartwig's Severity Assessment Scale and assessing QoL using St. George's respiratory Questionnaire. Chi-square test, analysis of variance, paired t-test were used to compare the data. The significance of change in adherence status was assessed by Wilcoxon signed-rank test. Results A total of 94 prescriptions of PTOAD were analyzed. Inhaled long-acting muscarinic antagonist was prescribed to 31.9% of patients. The most common inhaled fixed dose combination was long-acting beta-2 agonist with corticosteroid, prescribed to 52.1% of patients. At final follow-up, maximum percentage of patients were found to be highly adherent, i.e. 56.4%. Overall, 34% of patients have complained about mild category of ADRs. A significant improvement in QoL was observed. At baseline, mean forced expiratory volume in 1 (FEV1) was 64.66% ±23.61%, which increased significantly to 73.34% ±21.60% on final follow-up (P < 0.001). Conclusion Bronchodilators are the mainstay of treatment of PTOAD patients, since both the QoL and FEV1 were improved with treatments. However, to have good treatment outcome, strict adherence along with safety of the medications must be assured.
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Affiliation(s)
- Vinita Awasthi
- Department of Pharmacology and Therapeutics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sarvesh Singh
- Department of Pharmacology and Therapeutics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Narendra Kumar
- Department of Pharmacology and Therapeutics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Manoj Kumar
- Department of Pharmacology and Therapeutics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Amod Kumar Sachan
- Department of Pharmacology and Therapeutics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Rajiv Garg
- Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Rahul Kumar
- Department of Pharmacology and Therapeutics, King George's Medical University, Lucknow, Uttar Pradesh, India
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14
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Paulin MV, Caney SMA, Cosford KL. Online survey to determine client perceptions of feline chronic lower airway disease management: response to therapy, side effects and challenges encountered. J Feline Med Surg 2022; 24:1219-1227. [PMID: 35125012 PMCID: PMC9743080 DOI: 10.1177/1098612x211070988] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 12/31/2022]
Abstract
OBJECTIVES The first aim of this survey was to report client experiences associated with the administration of common medications, particularly glucocorticoids and bronchodilators, in managing cats with feline lower airway disease (FLAD). The second aim was to ascertain client perception of response to treatment and level of satisfaction. METHODS This was a prospective cross-sectional study. An online survey was distributed worldwide to cat owners caring for cats with a chronic cough. Only cats reported to have FLAD were included. RESULTS A total of 153 complete responses describing cats with FLAD were analyzed. Glucocorticoids and bronchodilators were the predominantly prescribed therapeutics for 140/153 (92%) and 80/153 (52%) of FLAD cats, respectively. Oral and inhalant administration routes were reported most commonly: glucocorticoids (64% oral and 75% inhalant) and bronchodilators (21% oral and 88% inhalant). A review of how air quality could be improved was conducted for 54% of cats. Almost half (43%) of owners reported adverse effects secondary to glucocorticoid administration, the most frequent being polyphagia (26%) and polydipsia (21%). Only 10% of owners reported bronchodilator-associated side effects, with restlessness (9%) being the most common. Difficulties giving glucocorticoid or bronchodilator tablets orally were reported for 33% and 71% of owners, respectively. Glucocorticoid or bronchodilator inhalant therapies were difficult to administer for 28% and 31% of owners, respectively. Frequency and severity of coughing were significantly lower after at least 2 months of treatment, with median numerical input on a slider scale (0-100) of 48 and 42 before, and 10 and 7 after treatment, respectively (P <0.0001). Median numerical input of owner satisfaction was 83%. CONCLUSIONS AND RELEVANCE Despite significant improvements in client-reported responses to treatment, challenges associated with the administration of medications and their adverse effects still exist. Promoting awareness of client experiences can facilitate appropriate follow-up, guidance and empathy to further optimize outcomes.
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Affiliation(s)
- Mathieu V Paulin
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Mathieu Victor Paulin DVM, IPSAV, Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK, S7N 5B2, Canada Emails:
| | - Sarah MA Caney
- Vet Professionals, Midlothian Innovation Centre, Pentlandfield, Roslin, UK
| | - Kevin L Cosford
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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15
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Levine H, Bar-On O, Nir V, West N, Dizitzer Y, Mussaffi H, Prais D. Reversible Bronchial Obstruction in Primary Ciliary Dyskinesia. J Clin Med 2022; 11:jcm11226791. [PMID: 36431268 PMCID: PMC9699262 DOI: 10.3390/jcm11226791] [Citation(s) in RCA: 1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inhaled bronchodilators are frequently used among patients with primary ciliary dyskinesia (PCD), although neither the effectiveness nor the prevalence of their use is known, due to the paucity of relevant studies. METHODS This is a retrospective analysis of pre- and post-bronchodilator spirometry results, of patients with PCD from two centers. Correlations were examined of bronchodilator response, with asthma and atopy markers. RESULTS Of 115 patients, 46 (40%) completed spirometry pre- and post-bronchodilation. Of these, 26 (56.5%) demonstrated reversible airway obstruction (increase in %FEV1 predicted ≥ 10%). Obstruction reversibility was not found to be associated with a family history of asthma, blood eosinophil level, elevated IgE, or atopy symptoms. Of the 46 patients who completed bronchodilator spirometry, 29 (63%) were regularly using bronchodilators and inhaled corticosteroids. CONCLUSIONS More than half of patients with PCD presented with reversible airway obstruction, without any correlation to markers of personal or familial atopy. Inhaled bronchodilators and corticosteroid therapies are commonly used for treating PCD. Evaluating bronchodilator response should be considered, and its effectiveness should be further studied.
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Affiliation(s)
- Hagit Levine
- Pulmonary Institute, Schneider Children’s Medical Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +97-23-925-3654; Fax: +97-23-925-3308
| | - Ophir Bar-On
- Pulmonary Institute, Schneider Children’s Medical Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Vered Nir
- Department of Pediatrics, Hillel-Yaffe Medical Center, Hadera 3810101, Israel
| | - Nicole West
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yotam Dizitzer
- Department of Pediatrics, Schneider Children’s Medical Center, Petah-Tikva 4920235, Israel
| | - Huda Mussaffi
- Pulmonary Institute, Schneider Children’s Medical Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Dario Prais
- Pulmonary Institute, Schneider Children’s Medical Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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16
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Fishe JN, Heintz H, Owusu-Ansah S, Schmucker K, Riney LC, Semenova O, Garvan G, Browne LR. Prehospital Pediatric Asthma Care during COVID-19: Changes to EMS Treatment Protocols and Downstream Clinical Effects. PREHOSP EMERG CARE 2022; 27:893-899. [PMID: 36260781 PMCID: PMC10164835 DOI: 10.1080/10903127.2022.2137864] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic, many emergency medical services (EMS) agencies modified treatment guidelines for clinical care and standard operating procedures. For the prehospital care of pediatric asthma exacerbations, modifications included changes to bronchodilator administration, systemic corticosteroid administration, and introduction of alternative medications. Since timely administration of bronchodilators and systemic corticosteroids has been shown to improve pediatric asthma clinical outcomes, we investigated the association of COVID-19 protocol modifications in the prehospital management of pediatric asthma on hospital admission rates and emergency department (ED) length-of-stay. METHODS This is a multicenter, retrospective, observational cohort study comparing prehospital pediatric asthma patients treated by EMS clinicians from four EMS systems before and after implementation of COVID-19 interim EMS protocol modifications. We included children ages 2-18 years who were treated and transported by ground EMS for respiratory-related prehospital primary complaints, and who also had asthma-related ED discharge diagnoses. Patient data and outcomes were compared from 12 months prior to and 12 months after the implementation of interim COVID-19 prehospital protocol modifications using univariate and multivariable statistics. RESULTS A total of 430 patients met inclusion criteria with a median age of 8 years. There was a slight male predominance (57.9%) and the majority of patients were African American (78.4%). There were twice as many patients treated prior to the COVID-19 protocol modifications (N = 287) compared to after (N = 143). There was a significant decrease in EMS bronchodilator administration from 76% to 59.4% of patients after COVID-19 protocol guidelines were implemented (p < 0.0001). Mixed effects models for hospital admission (to both pediatric inpatient units and pediatric intensive care units) as well as ED length-of-stay did not show any significant effect after the COVID-19 protocol change period (p = 0.18 and p = 0.55, respectively). CONCLUSIONS Despite a decrease in prehospital bronchodilator administration after COVID-19 changes to prehospital pediatric asthma management protocols, hospital admission rates and ED length-of-stay did not significantly increase. However, this finding is tempered by the marked decrease in study patients treated after COVID-19 prehospital protocol modifications. Given the potential for future waves of COVID-19 variants, further studies with larger patient populations are warranted.
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Affiliation(s)
- Jennifer N Fishe
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Hanna Heintz
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sylvia Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kyle Schmucker
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Lauren C Riney
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Olga Semenova
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gerard Garvan
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
| | - Lorin R Browne
- Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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17
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Miravitlles M, González-Torralba F, Represas-Represas C, Pomares X, Márquez-Martín E, González C, Amado C, Forné C, Alonso S, Alcázar B, Barrecheguren M, Jurado Mirete JM, Naval E. Pulmonologists' Opinion on the Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Patients in Spain: A Cross-Sectional Survey. Int J Chron Obstruct Pulmon Dis 2022; 17:1577-1587. [PMID: 35855745 PMCID: PMC9288191 DOI: 10.2147/copd.s369118] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD. Methods A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal. Results A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction. Conclusion In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain
| | | | | | - Xavier Pomares
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Pneumology Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Eduardo Márquez-Martín
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Medical-Surgical Unit for Respiratory Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Cruz González
- Pneumology Department, Hospital Clínico de Valencia, Valencia, Spain
| | - Carlos Amado
- Pneumology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carles Forné
- Heorfy Consulting, Lleida, Spain.,Basic Medical Sciences Department, University of Lleida, Lleida, Spain
| | - Soledad Alonso
- Pneumology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Bernardino Alcázar
- Pneumology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Elsa Naval
- Pneumology Department, Hospital Universitario de La Ribera, Alzira, Spain
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18
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Calverley PMA, Martinez FJ, Vestbo J, Jenkins CR, Wise R, Lipson DA, Cowans NJ, Yates J, Crim C, Celli BR. International Differences in the Frequency of Chronic Obstructive Pulmonary Disease Exacerbations Reported in Three Clinical Trials. Am J Respir Crit Care Med 2022; 206:25-33. [PMID: 35363593 PMCID: PMC9954323 DOI: 10.1164/rccm.202111-2630oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/16/2022] Open
Abstract
Rationale: Exacerbations of chronic obstructive pulmonary disease (COPD) are an important endpoint in multinational clinical treatment trials, but the observed event rate is often lower than anticipated and appears to vary between countries. Objectives: We investigated whether systematic differences in national exacerbation rates might explain this observed variation. Methods: We reviewed data from three large multicenter international randomized trials conducted over an 18-year period with different designs and clinical severities of COPD, comparing bronchodilator and/or inhaled corticosteroids with bronchodilators alone and/or placebo. Exacerbations were defined by antibiotic and/or oral corticosteroid use (moderate) or need for hospitalization (severe). We calculated crude exacerbation rates in the 30 countries contributing 30 or more patients to at least two trials. We grouped data by exacerbation rate based on their first study contribution. Measurements and Main Results: For the 29,756 patients in 41 countries analyzed, the mean exacerbation rate was two- to threefold different between the highest and lowest tertiles of the recruiting nations. These differences were not explained by demographic features, study protocol, or reported exacerbation history at enrollment. Of the 18 countries contributing to all trials, half of those in the highest and half in the lowest tertiles of exacerbation history remained in these groups across trials. Severe exacerbations showed a different rank order internationally. Conclusions: Countries contributing to COPD trials differ consistently in their reporting of healthcare-defined exacerbations. These differences help explain why large studies have been needed to show differences between treatments that decrease exacerbation risk.
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Affiliation(s)
- Peter M. A. Calverley
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Fernando J. Martinez
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, the University of Manchester, Manchester, United Kingdom;,Manchester University National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Christine R. Jenkins
- The George Institute for Global Health, Sydney, New South Wales, Australia;,University of New South Wales, Sydney, New South Wales, Australia
| | - Robert Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David A. Lipson
- Respiratory Clinical Sciences, GlaxoSmithKline plc., Collegeville, Pennsylvania;,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Julie Yates
- Research and Development, GlaxoSmithKline plc., Research Triangle Park, Durham, North Carolina; and
| | - Courtney Crim
- Research and Development, GlaxoSmithKline plc., Research Triangle Park, Durham, North Carolina; and
| | - Bartolome R. Celli
- Pulmonary and Critical Care Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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19
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Cazzola M, Rogliani P, Naviglio S, Calzetta L, Matera MG. An update on the currently available and emerging synthetic pharmacotherapy for uncontrolled asthma. Expert Opin Pharmacother 2022; 23:1205-1216. [PMID: 35621331 DOI: 10.1080/14656566.2022.2083955] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION : The treatment of uncontrolled asthma has improved because of triple therapy that includes a long-acting muscarinic antagonist (LAMA) and biological drugs, but several patients are resistant to corticosteroids and/or cannot achieve adequate asthma control using such therapies. AREAS COVERED : Herein, the authors review the current and emerging synthetic pharmacotherapy for uncontrolled asthma to overcome obstacles and limitations of biological therapies. The authors also provide their expert perspectives and opinion on the treatment of uncontrolled asthma. EXPERT OPINION : LAMAs should be added to inhaled corticosteroid/long-acting β2-agonist combinations much earlier than currently recommended by the Global Initiative for Asthma strategy because they can influence the course of small airways disease, reducing lung hyperinflation and improving asthma control. Biological therapies are a major advance in the treatment of severe asthma, but their use is still very limited for several reasons. An alternative to overcome the use of biological therapies is to synthesise compounds that target inflammation-signalling pathways. Several pathways have been identified as potential targets to design either therapeutic or prophylactic drugs against asthma. Some new compounds have already been tested in humans, but results have often been disappointing probably because existing phenotypic and endotypic variants may unpredictably limit the therapeutic value of blocking a specific pathway in most asthmatics, although there may be a substantial benefit for a subgroup of patients.
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Affiliation(s)
- 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
| | - Silvio Naviglio
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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Bhatt SP, Blauer-Peterson C, Buysman EK, Bengtson LGS, Paine Iii SR. Trends and Characteristics of Global Initiative for Chronic Obstructive Lung Disease Guidelines-Discordant Prescribing of Triple Therapy Among Patients with COPD. Chronic Obstr Pulm Dis 2022; 9:135-153. [PMID: 35157792 PMCID: PMC9166325 DOI: 10.15326/jcopdf.2021.0256] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Triple therapy (long-acting muscarinic antagonist [LAMA] plus long-acting beta2-agonist [LABA] plus inhaled corticosteroid [ICS]) is recommended by the Global initiative for chronic Obstructive Lung Disease (GOLD) for moderate-to-severe chronic obstructive pulmonary disease (COPD) with a history of frequent and/or severe exacerbation(s) and dyspnea while using dual bronchodilators. However, many patients receive triple therapy contrary to these recommendations. This study describes factors associated with GOLD-discordant triple therapy initiation. METHODS This retrospective analysis included patients aged 40 and above, with ≥1 COPD diagnosis, who initiated triple therapy (initiation=index date) during the period January 1, 2014 to December 31, 2018 and had ≥12 months pre-index continuous enrollment (baseline). Triple therapy comprised ≥30 days of overlapping LAMA, LABA, and ICS treatments (open triple therapy), or single-inhaler fluticasone furoate/umeclidinium/vilanterol (closed triple therapy). Cohorts were defined based on the absence of baseline maintenance medication use ("maintenance-naïve"), and/or exacerbations ("exacerbation-discordant"), or "dual-discordant" (discordant on both measures). All triple therapy initiators, overall and for each cohort, were described, and predictors of GOLD-discordant triple therapy initiation were identified. RESULTS Among 21,711 triple therapy initiators, 34.4% were maintenance-naïve, 61.9% exacerbation-discordant, and 22.2% dual-discordant. Triple therapy initiation appeared to increase during the period 2016 to 2018. In 2018 alone, 31.9% and 58.3% of open triple therapy patients were maintenance-naïve and exacerbation-discordant, respectively, versus 37.6% and 64.4% of closed triple therapy patients. Closed triple therapy initiators had 1.65 times greater risk of dual discordance than open triple therapy initiators. Exacerbation-discordant patients initiating closed triple therapy were 1.61 times more likely to be maintenance-naïve than those initiating open triple therapy. CONCLUSION A substantial proportion of COPD patients initiating triple therapy do not meet GOLD recommendations regarding exacerbation history and/or prior maintenance therapy. Compared with open triple therapy, closed triple therapy initiators were more likely to be dual discordant.
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Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Cori Blauer-Peterson
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, United States
| | - Erin K Buysman
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, United States
| | - Lindsay G S Bengtson
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, United States
| | - Swetha R Paine Iii
- Value Demonstration Team, Boehringer Ingelheim, Ridgefield, Connecticut, United States
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21
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Mitzel H, Brown D, Thomas M, Curl B, Wild M, Kelsch A, Muskrat J, Hossain A, Ryan K, Babalola O, Burgard M, Mehedi M. Patient-Centered Discussion on End-of-Life Care for Patients with Advanced COPD. Medicina (Kaunas) 2022; 58:254. [PMID: 35208578 PMCID: PMC8878082 DOI: 10.3390/medicina58020254] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/30/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
Abstract
Exacerbations of chronic obstructive pulmonary disease (COPD) may lead to a rapid decline in health and subsequent death, an unfortunate tyranny of having COPD-an irreversible health condition of 16 million individuals in the USA totaling 60 million in the world. While COPD is the third largest leading cause of death, causing 3.23 million deaths worldwide in 2019 (according to the WHO), most patients with COPD do not receive adequate treatment at the end stages of life. Although death is inevitable, the trajectory towards end-of-life is less predictable in severe COPD. Thus, clinician-patient discussion for end-of-life and palliative care could bring a meaningful life-prospective to patients with advanced COPD. Here, we summarized the current understanding and treatment of COPD. This review also highlights the importance of patient-centered discussion and summarizes current status of managing patients with advanced COPD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Masfique Mehedi
- School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA; (H.M.); (D.B.); (M.T.); (B.C.); (M.W.); (A.K.); (J.M.); (A.H.); (K.R.); (O.B.); (M.B.)
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22
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Zifodya JS, Triplette M, Shahrir S, Attia EF, Akgun KM, Soo Hoo GW, Rodriguez-Barradas MC, Wongtrakool C, Huang L, Crothers K. A cross-sectional analysis of diagnosis and management of chronic obstructive pulmonary disease in people living with HIV: Opportunities for improvement. Medicine (Baltimore) 2021; 100:e27124. [PMID: 34664836 PMCID: PMC8448060 DOI: 10.1097/md.0000000000027124] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/16/2021] [Indexed: 10/29/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is common in people living with HIV (PLWH). We sought to evaluate the appropriateness of COPD diagnosis and management in PLWH, comparing results to HIV-uninfected persons.We conducted a cross-sectional analysis of Veterans enrolled in the Examinations of HIV-Associated Lung Emphysema study, in which all participants underwent spirometry at enrollment and reported respiratory symptoms on self-completed surveys. Primary outcomes were misdiagnosis and under-diagnosis of COPD, and the frequency and appropriateness of inhaler prescriptions. Misdiagnosis was defined as having an International Classification of Diseases (ICD)-9 diagnosis of COPD without spirometric airflow limitation (post-bronchodilator forced expiratory volume in 1-second [FEV1]/Forced vital capacity [FVC] < 0.7). Under-diagnosis was defined as having spirometry-defined COPD without a prior ICD-9 diagnosis.The analytic cohort included 183 PLWH and 152 HIV-uninfected participants. Of 25 PLWH with an ICD-9 diagnosis of COPD, 56% were misdiagnosed. Of 38 PLWH with spirometry-defined COPD, 71% were under-diagnosed. In PLWH under-diagnosed with COPD, 85% reported respiratory symptoms. Among PLWH with an ICD-9 COPD diagnosis as well as in those with spirometry-defined COPD, long-acting inhalers, particularly long-acting bronchodilators (both beta-agonists and muscarinic antagonists) were prescribed infrequently even in symptomatic individuals. Inhaled corticosteroids were the most frequently prescribed long-acting inhaler in PLWH (28%). Results were overall similar amongst the HIV-uninfected.COPD was frequently misdiagnosed and under-diagnosed in PLWH, similar to uninfected-veterans. Among PLWH with COPD and a likely indication for therapy, long-acting inhalers were prescribed infrequently, particularly guideline-concordant, first-line long-acting bronchodilators. Although not a first-line controller therapy for COPD, inhaled corticosteroids were prescribed more often.
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Affiliation(s)
- Jerry S. Zifodya
- Department of Medicine, Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Matthew Triplette
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Shahida Shahrir
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Engi F. Attia
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Kathleen M. Akgun
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Grant W. Soo Hoo
- Department of Medicine, Pulmonary, Critical Care and Sleep Section, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Maria C. Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey Veterans Administration Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Cherry Wongtrakool
- Department of Medicine, Atlanta Veterans Administration Medical Center & Emory University School of Medicine, Atlanta, GA
| | - Laurence Huang
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Kristina Crothers
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Veterans Administration Puget Sound Health Care System, Seattle, WA
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23
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Mohan A, Ludwig A, Brehm C, Lugogo N, Sumino K, Hanania NA. Revisiting Mild Asthma: Current Knowledge and Future Needs. Chest 2021; 161:26-39. [PMID: 34543667 DOI: 10.1016/j.chest.2021.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 07/09/2021] [Revised: 08/22/2021] [Accepted: 09/09/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma is a common chronic airways disease with significant impact on patients, caregivers, and the health-care system. Although most research and novel interventions mainly have focused on patients with uncontrolled severe asthma, most patients with asthma have mild disease. Epidemiologic studies suggest that many patients with mild asthma report frequent exacerbations of the disease and uncontrolled symptoms. However, despite its impact, mild asthma does not have either a uniformly agreed on definition for or a consensus on its clinical and pathophysiologic progression. More recently, the approach to treatment of patients with mild asthma has undergone significant changes primarily based on emerging evidence that airway inflammation in this population is important. This led to clinical research studies that explored the efficacy of as-needed inhaled corticosteroids along with the rescue medications that traditionally have been the mainstay of treatment. Despite some advancement in the field in recent years, many controversies and unmet needs remain. In this review, we examine the current understanding of the pathophysiologic features and management of mild asthma. In addition, we outline unmet needs for future research. We conclude that mild asthma contributes significantly to the morbidity and mortality of asthma and should be the focus of future research.
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Affiliation(s)
- Arjun Mohan
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA.
| | - Amy Ludwig
- Department of Internal Medicine and Pediatrics, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Caryn Brehm
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Njira Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, MO
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX
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Csonka P, Tapiainen T, Mäkelä MJ, Lehtimäki L. Heterogeneity of emergency treatment practices in wheezing preschool children. Acta Paediatr 2021; 110:2448-2454. [PMID: 33987866 DOI: 10.1111/apa.15915] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 04/01/2021] [Accepted: 05/11/2021] [Indexed: 12/20/2022]
Abstract
AIM Our aim was to survey treatment practices used for preschool children with wheezing in emergency rooms (ER) focussing on inhalation device choice and handling, face mask use, salbutamol dosing and written instructions. We sought to assess whether current protocols are in line with published evidence and guidelines. METHODS This is a cross-sectional survey done in paediatric ER units located in Finnish municipalities with more than 10 000 inhabitants. RESULTS Of the 100 units contacted, 50% responded. More than 50% of the units used nebulisers. Only 13% of the units administered salbutamol in single puffs. More than 30% of the units lacked criteria on face mask use. Poor co-operation had no effect on the dose of salbutamol in 62% of the units. Ensuring tight mask-to-face seal was included in the training in 20% of the units. A written action plan was provided to the caregivers in 28% of the units. CONCLUSION ER treatment guidelines for preschool children with wheezing are poorly endorsed. Research is needed to identify approaches to guideline implementation that are specific for primary care. Clinical research should focus on strengthening recommendations that are currently not embraced. ER treatment protocols need to be updated and adherence to guidelines should be re-evaluated.
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Affiliation(s)
- Péter Csonka
- Centre for Child Health Research Tampere University and Tampere University Hospital Tampere Finland
- Terveystalo Healthcare Tampere Finland
| | - Terhi Tapiainen
- Department of Pediatrics and Adolescent Medicine Oulu University Hospital and PEDEGO Research Unit University of Oulu Oulu Finland
| | - Mika J. Mäkelä
- Skin and Allergy Hospital Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Lauri Lehtimäki
- Allergy Centre Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
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25
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D'Urzo AD, Singh D, Donohue JF, Chapman KR, Wise RA. Aclidinium bromide/formoterol fumarate as a treatment for COPD: an update. Expert Rev Respir Med 2021; 15:1093-1106. [PMID: 34137664 DOI: 10.1080/17476348.2021.1920403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Aclidinium/formoterol is a long-acting muscarinic antagonist (LAMA) and long-acting β2-agonist (LABA) dual bronchodilator used as a maintenance treatment for patients with chronic obstructive pulmonary disease (COPD). The efficacy of aclidinium/formoterol has been demonstrated consistently in patients with moderate-to-severe COPD versus placebo and monocomponents, with a comparable safety profile.Areas covered: This review examines recent research findings that expand our understanding of the impact of aclidinium/formoterol on the burden of COPD. Reviewed outcomes include improvements in lung function, respiratory symptoms, health-related quality of life, exercise tolerance, exacerbation rates, and clinically important deteriorations. In addition, the reported cardiovascular safety of aclidinium and current LAMA/LABA treatment recommendations are discussed.Expert opinion: Aclidinium/formoterol reduces disease burden in patients with COPD, including those that are treatment-naïve, without a significant increase in safety risk compared with monotherapies. Furthermore, evidence supports an improvement in lung function over a 24-hour period with aclidinium/formoterol treatment versus monotherapy and placebo, which may offer an advantage over some once-daily LAMA/LABA combinations. In summary, the recent evidence discussed in this review adds weight to the use of LAMA/LABA combinations as an initial therapy for certain patients newly diagnosed with COPD.
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Affiliation(s)
- Anthony D D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundations Trust, University of Manchester, Manchester, UK
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Pulmonary Critical Medicine, Chapel Hill, NC, USA
| | - Kenneth R Chapman
- Asthma and Airway Center, University Health Network, Toronto, ON, Canada
| | - Robert A Wise
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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26
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Lyu S, Li J, Wu M, He D, Fu T, Ni F, Tan X, Wu G, Pan B, Li L, Wang H, Zeng G, Ni Z, Tan W, Zong Y, Chen L, Liu P, Qin H, He P, Zhang L, An Y, Liang Z. The Use of Aerosolized Medications in Adult Intensive Care Unit Patients: A Prospective, Multicenter, Observational, Cohort Study. J Aerosol Med Pulm Drug Deliv 2021; 34:383-391. [PMID: 34129389 DOI: 10.1089/jamp.2021.0004] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Only limited data are available on the real-life clinical utilization of aerosolized medications in intensive care unit (ICU) patients. Exploring the utilization of aerosolized medications in the ICU may contribute to develop appropriate education and improve the quality of aerosol therapy. Methods: A 2-week, prospective, multicenter, observational, cohort study was conducted to record how the aerosolized medications were utilized in the Chinese ICUs, including indications, medications used in solo or combination, dosage, and side-effects in adult patients. Results: A total of 1006 patients from 28 ICUs were enrolled, of which 389 (38.7%) received aerosol therapy. The most common indications for aerosol therapy were difficulty in secretion management (23.1%) and chronic obstructive pulmonary disease exacerbation (18.5%). The combination of inhaled corticosteroids and short-acting muscarinic antagonist was the most commonly used medication (19.5%, 76/389). Ninety-two percent (358/389) of the patients did not have any side effects during aerosol therapy. More patients in the group with mechanical ventilation received bronchodilators than spontaneous breathing patients (81.3% vs. 55.5%, p < 0.001), and more patients who breathed spontaneously through a tracheostomy received mucus-regulating agents than other patients (70% vs. 37.9%, p = 0.004). Conclusion: In mainland China, more than one-third of adult ICU patients received aerosol therapy. Medications utilized during aerosol therapy were variable in patients with different respiratory support. To promote appropriate use of aerosolized medications, high-quality randomized, controlled trials and clinical guidance on aerosolized medication indications and dosing are needed to improve clinical outcomes.
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Affiliation(s)
- Shan Lyu
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Mengmeng Wu
- Department of Critical Care Medicine, Binzhou People's Hospital, Binzhou, China
| | - Dehua He
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tinggan Fu
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fang Ni
- Department of Respiratory and Critical Care Medicine, The Central Hospital of Wuhan, Wuhan, China
| | - Xu Tan
- Department of Respiratory and Critical Care Medicine, Union Hospital Affiliated with Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Guanghan Wu
- Department of Critical Care Medicine, People's Hospital of Jianghua Yao Autonomous County, Yongzhou, China
| | - Binhai Pan
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing, China
| | - Liucun Li
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Haiyan Wang
- Department of Emergency Critical Care Medicine, West China Hospital Sichuan University-Ziyang Hospital, Ziyang, China
| | - Guilan Zeng
- Department of Critical Care Medicine, Zhangzhou Hospital Traditional Chinese Medicine, Zhangzhou, China
| | - Zhong Ni
- Department of Respiratory and Critical Care Medicine, West China Medical Center, Sichuan University, Chengdu, China
| | - Wei Tan
- Department of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Yajuan Zong
- Department of Critical Care Medicine, Yixing No.2 People's Hospital, Yixing, China
| | - Lihua Chen
- Department of Critical Care Medicine, Gansu Second Provincial People's Hospital, Lanzhou, China
| | - Ping Liu
- Department of Critical Care Medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Hao Qin
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, Shanghai, China
| | - Ping He
- Department of Cardiac Surgery, Southwest Hospital, The First Hospital Affiliated to Army Medical University, Chongqing, China
| | - Liu Zhang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical Center, Sichuan University, Chengdu, China
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Hvisdas C. Revefenacin, a once-daily, long-acting muscarinic antagonist, for nebulized maintenance therapy in patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm 2021; 78:1184-1194. [PMID: 33821890 PMCID: PMC8083528 DOI: 10.1093/ajhp/zxab154] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This article reviews the efficacy and safety of revefenacin, the first once-daily, long-acting muscarinic antagonist, when delivered via a standard jet nebulizer in patients with chronic obstructive pulmonary disease (COPD). SUMMARY Revefenacin 175 µg is indicated for the maintenance treatment of patients with moderate to very severe COPD. Preclinical studies showed that revefenacin is a potent and selective antagonist with similar affinity for the different subtypes of muscarinic receptors (M1-M5). Furthermore, prevention of methacholine- and acetylcholine-induced bronchoconstrictive effects was dose dependent and lasted longer than 24 hours, demonstrating a long duration of action. In phase 2 and 3 trials, treatment with revefenacin was demonstrated to result in statistical improvements in pulmonary function (≥100 mL, P < 0.05) vs placebo, including among patients with markers of more severe disease and those who received concomitant long-acting β-agonists or long-acting β-agonists together with inhaled corticosteroids. Revefenacin was also demonstrated to have efficacy similar to that of tiotropium. The clinical trial findings indicated no significant difference between revefenacin and tiotropium with regard to rates of adverse events. Overall, revefenacin was well tolerated, with COPD worsening/exacerbation, dyspnea, headache, and cough among the most common adverse events noted in the clinical trials. CONCLUSIONS Revefenacin treatment delivered via nebulization led to improvements in lung function in patients with COPD. It was also generally well tolerated, with no major safety concerns. Revefenacin provides a viable treatment option for patients with COPD and may be a suitable alternative for those with conditions that may impair proper use of traditional handheld inhalers.
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Affiliation(s)
- Christopher Hvisdas
- Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA
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28
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Mahler DA, Halpin DMG. Peak Inspiratory Flow as a Predictive Therapeutic Biomarker in COPD. Chest 2021; 160:491-498. [PMID: 33812852 DOI: 10.1016/j.chest.2021.03.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/21/2021] [Accepted: 03/28/2021] [Indexed: 11/19/2022] Open
Abstract
Biomarkers in COPD may be clinical (prior exacerbation history), physiologic (FEV1), or blood based (eosinophil count or fibrinogen level). Recent interest in using biomarkers to predict response to therapy in clinical practice has emerged. The benefits of inhaled therapy depend on the correct use of the inhaler, including an appropriate inspiratory flow. Of the available delivery systems, dry powder inhalers are unique because they have an internal resistance, are breath actuated, and are flow dependent. Ideally, the user inhales "forcefully" to generate turbulent energy (determined by an individual's inspiratory flow and the resistance of the device) within the device that disaggregates the powder so that the individual inhales the medication particles into the lower respiratory tract. Because of specific features of dry powder inhalers and the required optimal inspiratory flow, an unmet need exists to identify individuals who are likely or unlikely to benefit from dry powder medications. Peak inspiratory flow, defined as the maximum airflow generated during inhalation against the simulated resistance of a dry powder inhaler, is a physiologic measure that has biological plausibility, has good test characteristics (repeatability and reliability), and is generalizable. Current evidence supports peak inspiratory flow as a predictive therapeutic biomarker to optimize therapy in both outpatients with COPD as well as those hospitalized for an exacerbation before discharge. This approach is consistent with the precepts of precision medicine, which considers differences in a person's biological features, exposure, and lifestyle to prevent and treat disease.
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Affiliation(s)
- Donald A Mahler
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Respiratory Services, Valley Regional Hospital, Claremont, NH.
| | - David M G Halpin
- Department of Respiratory Medicine, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, England
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29
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Tantucci C. Assessment and treatment of airflow obstruction in patients with chronic obstructive pulmonary disorder: a guide for the clinician. Expert Rev Respir Med 2021; 15:385-391. [PMID: 33215956 DOI: 10.1080/17476348.2021.1851602] [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: 10/23/2022]
Abstract
Introduction: Chronic obstructive pulmonary disorder (COPD) is a common cause of disability, morbidity and mortality worldwide. Early diagnosis and adequate treatment maintained over time are crucial to reducing these harmful consequences.Areas covered Persistent, not reversible and naturally progressive airflow obstruction is the functional hallmark of COPD. Therefore, in the presence of individual and environmental risk factors, with or without reported suggestive symptoms, simple spirometry must be performed enough quickly to objectify an obstructive ventilatory defect and assist physicians in making a diagnosis of COPD. Then, to cope with the heterogeneity of COPD patients, more specific functional tests and imaging techniques should be implemented to better define the underlying prevalent disease and its severity. That is necessary to decide whether to introduce ICS and establish the initial level of the treatment with just one or two bronchodilators, to control and freeze, when possible, the underlying pathological process.Expert opinion: The objective assessment of airflow obstruction is mandatory to make a diagnosis of COPD, but the prevalent disease sustaining the disorder should also be investigated to select a targeted therapy, because main determinants of airflow obstruction can be different in COPD patients and may differently respond to treatment.
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Affiliation(s)
- Claudio Tantucci
- Department of Clinical and Experimental Sciences, Respiratory Medicine Unit, Spedali Civili Brescia, University of Brescia, Brescia, Italy
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Chen TY, Su VYF, Lee CH, Chung CH, Tsai CK, Peng CK, Lai HC, Chien WC, Tzeng NS. The Association Between Asthma and Narcolepsy: A Nationwide Case-Control Study in Taiwan. Nat Sci Sleep 2021; 13:1631-1640. [PMID: 34584477 PMCID: PMC8464343 DOI: 10.2147/nss.s317746] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/08/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Asthma, which is caused by inflammation of the airways, affects the sensitivity of nerve endings. Narcolepsy is a chronic sleep disorder that may be caused by autoimmunity. Recent studies have reported a positive association between narcolepsy and asthma. We aimed to examine the association between asthma and narcolepsy and determine the effects of therapeutic corticosteroid or bronchodilator use. MATERIALS AND METHODS We conducted a nationwide population-based, nested case-control study using Taiwan's National Health Insurance Research Database (NHIRD) between 2000 and 2013. Subjects with narcolepsy (ICD-9-CM code 347) were enrolled, with 1:3 estimated propensity score-matched controls based on sex, age, and index year. The association between narcolepsy and asthma was assessed using multiple logistic regression analyses. The covariates included sex, age, monthly insurance premiums, geographical area of residence, urbanization level of residence, level of care, and presence of diseases related to immune response and central nervous system. The effects of corticosteroid and bronchodilator use were also analyzed. RESULTS Overall, 2008 subjects were identified from the NHIRD (502 patients with narcolepsy and 1506 controls). The participants with narcolepsy had almost three times the level of previous asthma diagnosis than controls. Compared to those without asthma, patients with asthma had an adjusted odds ratio (OR) of 3.181 for narcolepsy comorbidity (95% confidence interval [CI]: 2.048-4.941, p<0.001). The use of inhaled corticosteroids was associated with a lower risk of narcolepsy comorbidity, with an adjusted OR of 0.465 (95% CI, 0.250-0.634; p<0.001), in patients with asthma when compared to those without treatment. CONCLUSION This study demonstrated a significantly higher level of previous asthma diagnosis in patients with narcolepsy. The use of inhaled corticosteroids was associated with a lower risk of narcolepsy comorbidity in asthma patients, compared to those without treatment.
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Affiliation(s)
- Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan.,Sleep Medicine Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Vincent Yi-Fong Su
- Department of Internal Medicine, Taipei City Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan
| | - Chung-Hsin Lee
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Chia-Kuang Tsai
- Sleep Medicine Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Department of Neurology, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Kan Peng
- Sleep Medicine Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Hsiao-Ching Lai
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
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Irusen EM, Malange T. Pharmacotherapy of chronic obstructive pulmonary disease: Therapeutic considerations with a focus on inhaled corticosteroids. S Afr Fam Pract (2004) 2020; 62:e1-e6. [PMID: 33314947 PMCID: PMC8378153 DOI: 10.4102/safp.v62i1.5198] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/01/2022] Open
Abstract
International and national guidelines on chronic obstructive pulmonary disease (COPD) emphasise bronchodilators as first-line therapy. However, in considering them the 'foundation' of treatment, attention has shifted from the fact that COPD is fundamentally an inflammatory disease. The mainstay ought to be anti-inflammatory medication, and inhaled corticosteroids (ICS) are the best agents we have presently. There was initial scepticism about their role, but ICS were subsequently shown to have numerous anti-inflammatory effects. They are synergistic with bronchodilators at a molecular and clinical level and unequivocally improve dyspnoea, quality of life, exacerbation frequency and, more recently, mortality. These benefits are most apparent in the COPD eosinophilic phenotype. These beneficial effects have been met with some reservations because of the predisposition to pneumonia of ICS. This must be seen in context: over 90% of COPD patients in all clinical trials do not get pneumonia. The fact that patients with COPD are predisposed to pneumonia because of the disease itself is disregarded; this is a crucial omission as this constitutes the baseline incidence of about 3%. When one allows for this, then in the clinical reports, the excess risk of pneumonia ranges from zero to a maximum of 3%. Equally, some of the systemic effects attributed to ICS fail to appreciate that the disease, smoking and older age are risk factors in themselves, and ICS do not aggravate these. Chronic obstructive pulmonary disease has considerable impact on respiratory reserve and is associated with increasing morbidity; optimal outcomes are best achieved with long-acting bronchodilators and ICS co-prescription.
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Affiliation(s)
- Elvis M Irusen
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Tygerberg Hospital, Cape Town.
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Shlomi D, Oberman B, Katz I. Short-acting bronchodilators purchase as a marker for asthma control. J Asthma 2020; 59:206-212. [PMID: 33125311 DOI: 10.1080/02770903.2020.1837157] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Administrative data has been used to quantify the amount of medication use in order to identify at-risk asthma patients. In our previous study we used short-acting beta-agonists (SABA) inhalers as a marker for asthma control. METHODS We further analyzed patient data from the SABA inhalers study in which asthma control was classified by GINA guidelines, physician assessment and the patients overall estimation. We identified all short-acting bronchodilator purchases (SABA and anticholinergic inhalers and solutions) in the year prior to administering the questionnaire relating to asthma control, and compared inhaled and systemic steroid use. RESULTS Of 241 asthma patients, 83 completed questionnaires. Using the GINA guidelines criteria, 26 were symptom controlled, 46 were partially controlled and 11 were uncontrolled. Using patients' overall impression of their asthma control, mean annual short-acting bronchodilator purchases were significantly higher in the partially controlled and uncontrolled patients (10 and 8.9 respectively) than in the controlled patients (2, p = 0.005). Most asthma patients purchase less than half of the controller medications prescribed to them. CONCLUSION When using administrative data, 3 or more -of all types of short-acting bronchodilator purchases in one year should alert the physician to evaluate asthma control and purchase alerts should notify both physicians and patients when controller consumption is low.
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Affiliation(s)
- Dekel Shlomi
- Adelson School of Medicine, Ariel University, Ariel, Israel.,Pulmonary Clinic, Clalit Health Services, Dan- Petah-Tiqwa District, Israel
| | - Bernice Oberman
- The Biostatistics & Biomathematics Unit, The Gertner Institute for Epidemiology and Health Policy Research, Ramat-Gan, Israel
| | - Irit Katz
- Department of Neurological Rehabilitation, Sheba Medical Center, Ramat-Gan, Israel
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Gershon AS, McGihon RE, Thiruchelvam D, To T, Wu R, Bell CM, Aaron SD. Medication Discontinuation in Adults With COPD Discharged From the Hospital: A Population-Based Cohort Study. Chest 2020; 159:975-984. [PMID: 33011204 DOI: 10.1016/j.chest.2020.09.254] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation. RESEARCH QUESTION What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD? STUDY DESIGN AND METHODS A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort. RESULTS Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P < .001] and 1.62 [95% CI, 1.39, 1.90; P < .001] for LAMA and LABA-ICS, respectively). Crude rates of discontinuation for people taking LAMAs were 5.2% in the hospitalization group and 3.3% in the community group; for people taking LABA-ICS, these rates were 5.5% in the hospitalization group and 3.1% in the community group. INTERPRETATION In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.
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Affiliation(s)
- Andrea S Gershon
- Department of Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Rachel E McGihon
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Teresa To
- ICES, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robert Wu
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine, University Health Network, Toronto, ON, Canada
| | - Chaim M Bell
- ICES, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Sinai Health System, Toronto, ON, Canada
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, ON, Canada
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Medeiros D, Castro P, Bianca ACD, Sarinho E, Araújo JF, Correia Junior M, Rizzo JA. Impulse oscillometry: pulmonary function assessment in preschool children. Expert Rev Respir Med 2020; 14:1261-1266. [PMID: 32852224 DOI: 10.1080/17476348.2020.1813573] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES In contrast to spirometry, which requires active participation of the individual and is challenging for the preschool age group, the impulse oscillometry system comprises a test that minimizes the degree of coordination required. The study aimed to compare the results of Impulse Oscillometry System (IOS) in children with and without respiratory symptoms. METHODS A cross-sectional study was conducted in children aged between 3 and 6 years. A short version of the ATS-DLD-78-C questionnaire validated for Brazilian children was applied to identify two groups: children with and without respiratory symptoms. The IOS analysis was carried out measuring the following parameters in triplicate: resistance at 5 Hz (R5Hz) and 20 Hz (R20Hz), respiratory reactance at 5 Hz (X5Hz), and R5-R20Hz before and after bronchodilator application. RESULTS A total of 76 preschoolers were selected, 55 (72.4%) of whom had respiratory complaints. The coefficient of variability of R5Hz was ≤17% in 70/76 (92.1%) of the children. Resistances at R5Hz and R5-R20Hz in the children with respiratory complaints reached values higher than those of children without symptoms before bronchodilation. CONCLUSIONS The results obtained for resistance using IOS in children with respiratory symptoms were higher in the pre-bronchodilator examination for R5Hz and R5-R20Hz compared to those of children without respiratory symptoms. EXPERT OPINION Prospective investigations suggest that irreversible changes in lung function begin in infancy, before reaching school age. Pulmonary function follow-up in children with recurrent wheezing or asthma is important for confirmation of diagnosis and evaluation of the disease severity. The Impulse Oscillometry System (IOS) can be useful in assessing children's pulmonary function since it requires minimal patient cooperation and can be successfully applied to preschool children being an alternative to individuals who have difficulty performing spirometry.
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Affiliation(s)
- Décio Medeiros
- Department of Maternal-Child Health, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil.,Allergy and Immunology Research Center, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil
| | - Pedro Castro
- Allergy and Immunology Research Center, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil.,Undergraduate Faculty Member in Medicine, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil
| | - Ana Caroline Dela Bianca
- Department of Maternal-Child Health, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil.,Allergy and Immunology Research Center, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil
| | - Emanuel Sarinho
- Department of Maternal-Child Health, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil.,Allergy and Immunology Research Center, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil
| | - Jaqueline Figueirôa Araújo
- Allergy and Immunology Research Center, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil.,Master of Science in Health, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil
| | - Marco Correia Junior
- Allergy and Immunology Research Center, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil.,Postgraduate Program in Hebiatrics and Physical Education, Universidade de Pernambuco (UPE) , Recife, Brazil
| | - Jose Angelo Rizzo
- Allergy and Immunology Research Center, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil.,Department of Clinical Medicine, Universidade Federal de Pernambuco (UFPE) , Recife, Brazil
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Albertson TE, Pugashetti JV, Chau-Etchepare F, Chenoweth JA, Murin S. Pharmacotherapeutic management of asthma in the elderly patient. Expert Opin Pharmacother 2020; 21:1991-2010. [PMID: 32686969 DOI: 10.1080/14656566.2020.1795131] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines. AREAS COVERED A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed. EXPERT OPINION Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Florence Chau-Etchepare
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
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Adrien N, Petersen JM, Parker SE, Werler MM. Vasoactive exposures and risk of amniotic band syndrome and terminal transverse limb deficiencies. Birth Defects Res 2020; 112:1074-1084. [PMID: 32573119 DOI: 10.1002/bdr2.1740] [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: 04/07/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Amniotic band syndrome (ABS) includes limb deficiencies accompanied by fibrous strands originating from the amniotic lining. Terminal transverse limb deficiencies (TTLD) appear to be similar but lack fibrous strands. Both are hypothesized to result from vascular disruption. For ABS, limb deficiencies are considered secondary to amnion rupture. We explored an alternative possibility-that TTLD is the primary defect and ABS is secondary. METHODS Using data from the National Birth Defects Prevention Study, we expanded on a previous study. We examined smoking, alcohol, and medications categorized by indicated vasoactivity as markers of vascular disruption. Logistic regression models with Firth's penalized likelihood were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS Use of bronchodilators and aspirin appeared to increase the risk of ABS, while decongestants and nonaspirin NSAIDs increased the risk of TTLD. The risk of ABS was markedly increased in cases reporting combinations of vasoactive exposures, particularly alcohol and aspirin (aOR 3.7, 95% CI 1.6, 7.8), and alcohol and bronchodilators (aOR 3.4, 95% CI 1.4, 7.5). Increased risk of TTLD due to combinations of vasoactive exposures was only observed for smoking and decongestants (aOR 2.3, 95% CI 1.4, 3.6). CONCLUSIONS Exposures associated with increased risk of ABS had no apparent association with TTLD, supporting previous evidence that these may be distinct phenotypes. ABS appears to be associated with combined exposures with vasodilation properties, such as alcohol and bronchodilators, while increased risk of TTLD may be associated with smoking and decongestants, both vasoconstrictive exposures.
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Affiliation(s)
- Nedghie Adrien
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Julie M Petersen
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Samantha E Parker
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Martha M Werler
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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Plate T, Friedrich FW, Beier J. Effectiveness and Tolerability of LABA/LAMA Fixed-Dose Combinations Aclidinium/Formoterol, Glycopyrronium/Indacaterol and Umeclidinium/Vilanterol in the Treatment of COPD in Daily Practice - Results of the Non-Interventional DETECT Study. Int J Chron Obstruct Pulmon Dis 2020; 15:1335-1347. [PMID: 32606643 PMCID: PMC7293910 DOI: 10.2147/copd.s252354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 03/03/2020] [Accepted: 05/24/2020] [Indexed: 11/23/2022] Open
Abstract
Background LABA (long-acting β2-agonists) and/or LAMA (long-acting muscarinic antagonists) represent the first treatment options for patients with symptomatic COPD. Although both display different mechanisms of activity, in combination they have a stronger broncho-dilating effect than monotherapy; hence, a combination of both LABA and LAMA is particularly recommended for patients whose symptoms cannot be sufficiently improved by a single active ingredient. To date, only few data have been collected regarding the therapeutic outcomes of approved LABA/LAMA fixed-dose combinations (FDCs) under everyday (real-life) conditions in non-clinical trial settings. Objective and Methods The main objective of the DETECT study was to investigate the impact of aclidinium/formoterol (AB/FF, b.i.d.), glycopyrronium/indacaterol (GLY/IND, q.d.) and umeclidinium/vilanterol (UME/VL, q.d.) in patients with COPD in daily clinical practice. Therefore, a prospective, non-randomized, 12-month, observational study was implemented to assess the effectiveness of these treatments in patients who had been switched to FDC within the last 3 months or for whom such a changeover was intended. Changes in lung function were analyzed by the forced expiratory volume (FEV1) and forced vital capacity (FVC) measures. Quality of life and well-being were evaluated by the COPD Assessment Test (CAT™). Furthermore, a number of exacerbations and early morning COPD symptoms were documented. Results In total, 3653 patients were enrolled. FEV1 and FVC values significantly improved during the study with AB/FF (increase by 0.09 ± 0.40 L and 0.10 ± 0.57 L, respectively; p<0.0001), GLY/IND (0.06±0.38/0.05±0.51 L; p<0.0001 and p=0.0025) and UME/VL (0.12±0.39/0.10±0.52 L; p<0.0001). CAT scores decreased indicating improved COPD (AB/FF, 4.17±8.30; GLY/IND, 3.66±7.88; UME/VL, 4.06±7.96; p<0.0001). Moreover, the number of exacerbations as well as early morning COPD symptoms similarly diminished in all treatment groups. A comparable proportion of patients with adverse drug reactions was recorded: AB/FF, 4.07% of patients; GLY/IND, 3.52%; UME/VL, 3.64%. Conclusion In summary, AB/FF, GLY/IND and UME/VL provided clinical benefits in lung function, quality of life and early morning COPD symptoms in a broad cohort of COPD patients under routine medical practice conditions. All three treatments were well tolerated.
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Affiliation(s)
| | | | - Jutta Beier
- Insaf - Respiratory Research Institute GmbH, Wiesbaden, Germany
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Selvanathan J, Aaron SD, Sykes JR, Vandemheen KL, FitzGerald JM, Ainslie M, Lemière C, Field SK, McIvor RA, Hernandez P, Mayers I, Mulpuru S, Alvarez GG, Pakhale S, Mallick R, Boulet LP, Gupta S. Performance Characteristics of Spirometry With Negative Bronchodilator Response and Methacholine Challenge Testing and Implications for Asthma Diagnosis. Chest 2020; 158:479-490. [PMID: 32298731 DOI: 10.1016/j.chest.2020.03.052] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/27/2020] [Accepted: 03/21/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND In patients with a history suggestive of asthma, diagnosis is usually confirmed by spirometry with bronchodilator response (BDR) or confirmatory methacholine challenge testing (MCT). RESEARCH QUESTION We examined the proportion of participants with negative BDR testing who had a positive MCT (and its predictors) result and characteristics of MCT, including effects of controller medication tapering and temporal variability (and predictors of MCT result change), and concordance between MCT and pulmonologist asthma diagnosis. STUDY DESIGN AND METHODS Adults with self-reported physician-diagnosed asthma were recruited by random-digit dialing across Canada. Subjects performed spirometry with BDR testing and returned for MCT if testing was nondiagnostic for asthma. Subjects on controllers underwent medication tapering with serial MCTs over 3 to 6 weeks. Subjects with a negative MCT (the provocative concentration of methacholine that results in a 20% drop in FEV1 [PC20] > 8 mg/mL) off medications were examined by a pulmonologist and had serial MCTs after 6 and 12 months. RESULTS Of 500 subjects (50.5 ± 16.6 years old, 68.0% female) with a negative BDR test for asthma, 215 (43.0%) had a positive MCT. Subjects with prebronchodilator airflow limitation were more likely to have a positive MCT (OR, 1.90; 95% CI, 1.17-3.04). MCT converted from negative to positive, with medication tapering in 18 of 94 (19.1%) participants, and spontaneously over time in 25 of 165 (15.2%) participants. Of 231 subjects with negative MCT, 28 (12.1%) subsequently received an asthma diagnosis from a pulmonologist. INTERPRETATION In subjects with a self-reported physician diagnosis of asthma, absence of bronchodilator reversibility had a negative predictive value of only 57% to exclude asthma. A finding of spirometric airflow limitation significantly increased chances of asthma. MCT results varied with medication taper and over time, and pulmonologists were sometimes prepared to give a clinical diagnosis of asthma despite negative MCT. Correspondingly, in patients for whom a high clinical suspicion of asthma exists, repeat testing appears to be warranted.
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Affiliation(s)
- Janannii Selvanathan
- Keenan Research Center in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Jenna R Sykes
- Department of Medicine, Division of Respirology, St. Michael's Hospital, Toronto, ON
| | | | - J Mark FitzGerald
- Centre for Heart and Lung Health, Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Martha Ainslie
- Department of Medicine, University of Manitoba, Winnipeg, MB
| | | | - Stephen K Field
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - R Andrew McIvor
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, QEII Health Sciences Centre, Halifax, NS
| | - Irvin Mayers
- Department of Medicine, University of Alberta, Edmonton, AB
| | - Sunita Mulpuru
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Gonzalo G Alvarez
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Smita Pakhale
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | | | - Samir Gupta
- Keenan Research Center in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, St. Michael's Hospital, Toronto, ON.
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Abstract
Approximately 20% of patients with obstructive lung disease have features of both asthma and chronic obstructive pulmonary disease These patients have a higher burden of disease and increased exacerbations compared to those with asthma or chronic obstructive pulmonary disease alone Management should address dominant clinical features in each individual patient, and comorbidities should be considered There are several interventions that are useful in the management of both asthma and chronic obstructive pulmonary disease As inhaled corticosteroids are key to the management of asthma, they are recommended in patients with overlapping chronic obstructive pulmonary disease
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Affiliation(s)
- Anne Knight
- Hunter New England Local Health District, Taree, NSW.,University of Newcastle Department of Rural Health, NSW
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40
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D'Urzo AD, Singh D, Donohue JF, Chapman KR. Aclidinium bromide in fixed-dose combination with formoterol fumarate in the management of COPD: an update on the evidence base. Ther Adv Respir Dis 2019; 13:1753466619850725. [PMID: 31096854 PMCID: PMC6535700 DOI: 10.1177/1753466619850725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Aclidinium bromide/formoterol fumarate (AB/FF) 400/12 µg is a twice-daily long-acting muscarinic receptor antagonist and long-acting β2 agonist (LAMA/LABA) dual-bronchodilator maintenance therapy used to relieve symptoms and reduce future risk of exacerbations in adults with chronic obstructive pulmonary disease (COPD). To date, there have been several clinical studies and post hoc analyses of AB/FF, assessing treatment outcomes in patients with moderate-to-severe COPD. These studies have looked at a range of outcomes, including lung function parameters, patient-reported symptom scores, quality-of-life measures assessing impaired health and perceived well-being, and the frequency, duration, and severity of exacerbations. In light of the major 2017 revision to the Global initiative for chronic Obstructive Lung Disease (GOLD) recommendations, and the subsequent updates, we present an update on the latest evidence supporting the efficacy and safety of AB/FF. This review discusses the clinical relevance of the improvements in lung function, symptoms, quality of life, and exacerbations in patients with COPD reported in the phase III and IV trials of AB/FF. Given the current concerns over unnecessary inhaled corticosteroid (ICS) use in COPD, we also touch briefly on the use of blood eosinophils as a biomarker for identifying those patients with COPD already using LAMA/LABA therapy for whom the addition of ICS might be of benefit.
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Affiliation(s)
- Anthony D D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON 12354, Canada
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundations Trust, Manchester, UK
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Pulmonary Critical Medicine, Chapel Hill, NC, USA
| | - Kenneth R Chapman
- Asthma and Airway Center, Toronto Western Hospital, Toronto, ON, Canada
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Abstract
Bronchiectasis is a chronic inflammatory condition with a diverse aetiology including recurrent infections, genetic abnormalities, immunodeficiency and autoimmune disorders. The prevalence has increased over the past few years and this may be due to better imaging and diagnostic techniques. Management remains the emphasis for improving symptoms and reducing exacerbations. This article focuses on highlighting the latest data released since 2014 on new diagnostic techniques as well as potential future pharmacological and non-pharmacological treatment options for patients with bronchiectasis.
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Li C, Cheng W, Guo J, Guan W. Relationship of inhaled long-acting bronchodilators with cardiovascular outcomes among patients with stable COPD: a meta-analysis and systematic review of 43 randomized trials. Int J Chron Obstruct Pulmon Dis 2019; 14:799-808. [PMID: 31114181 PMCID: PMC6489598 DOI: 10.2147/copd.s198288] [Citation(s) in RCA: 12] [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] [Received: 12/14/2018] [Accepted: 02/22/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Long-acting muscarinic antagonists (LAMAs) and long-acting β2–agonists (LABAs) are the mainstay of maintenance therapy for chronic obstructive pulmonary disease (COPD). Although previous studies have supported inhaled long-acting bronchodilators (ILABs) for overall cardiovascular safety, the risk of specific cardiovascular outcomes such as arrhythmia, heart failure and stroke is still unknown. Materials and methods: We systematically searched from PubMed, the Embase database and the Cochrane Library for published studies on ILABs and COPD, from its inception to November 10, 2018, with no language restrictions. The RRs and corresponding 95% CIs were pooled to evaluate ILAB/placebo. Results: Finally, 43 randomized controlled trials were included. Compared with placebo, ILABs do not increase the risk of overall and specific cardiovascular adverse events (AEs); on the contrary, they can reduce the incidence of hypertension (RR 0.73, 95% CI 0.55–0.98;I219.9%; P= 0.221). However, when stratified according to the specific agents of ILABs, olodaterol might reduce the risk of overall cardiovascular adverse events (OCAEs) (RR 0.65, 95% CI 0.49–0.88;I227.5%; P= 0.000), and the protective effect of lowing blood pressure disappeared. Similarly, the use of inhaled LABA might increase the risk of cardiac failure (RR 1.71, 95% CI 1.04–2.84;I20%; P= 0.538), but this risk disappeared when stratified according to the specific agents of LABA. Besides, formoterol might decrease the risk of cardiac ischemia (RR 0.53, 95% CI 0.32–0.91; I20%; P= 0.676). Conclusions: Overall, the use of ILABs was not associated with overall cardiovascular AEs in patients with stable COPD. When stratified according to the specific agents of LABA, olodaterol might reduce the risk of OCAE; and formoterol might decrease the risk of cardiac ischemia. LABA might reduce the incidence of hypertension, but might increase the risk of heart failure. Therefore, COPD patients with a history of heart failure should use it with caution.
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Affiliation(s)
- Chenxi Li
- Department of Respiratory, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
| | - Wenke Cheng
- Department of Cardiology, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
| | - Jin Guo
- Department of Respiratory, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
| | - Wei Guan
- Department of Respiratory, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
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Jardim JR, Nascimento OA. The Importance of Inhaler Adherence to Prevent COPD Exacerbations. Med Sci (Basel) 2019; 7:medsci7040054. [PMID: 30939829 PMCID: PMC6524014 DOI: 10.3390/medsci7040054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/25/2019] [Indexed: 11/16/2022] Open
Abstract
It has been shown that the better outcomes of chronic obstructive pulmonary disease (COPD) are closely associated with adherence to drug therapy, independent of the treatment administered. The clinical trial Towards a Revolution in COPD Health (TORCH) study clearly showed in a three year follow up that patients with good adherence to their inhaler treatment presented a longer time before the first exacerbation, a lower susceptibility to exacerbation and lower all-cause mortality. The Latin American Study of 24-h Symptoms in Chronic Obstructive Pulmonary Disease (LASSYC), a real-life study, evaluated the self-reported inhaler adherence in COPD patients in seven countries in a cross-sectional non-interventional study and found that approximately 50% of the patients had good adherence, 30% moderate adherence and 20% poor adherence. Adherence to inhaler may be evaluated by the specific inhaler adherence questionnaire, the Test of Adherence to Inhalers (TAI). Several factors may predict the incorrect use of inhalers or adherence in COPD outpatient, including the number of devices and the daily dosing frequency. Ideally, patient education, simplicity of the device operation, the use of just one device for multiple medications and the best adaptation of the patient to the inhaler should guide the physician in prescribing the device.
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Affiliation(s)
- Jose R Jardim
- Respiratory Division, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/Unifesp), São Paulo 04023-062, Brazil.
- Pulmonary Rehabilitation Unit, EPM/Unifesp, São Paulo 04023-062, Brazil.
- Regional Medical Expert at GlaxoSmithKline (GSK), Rio de Janeiro 22783-110, Brazil.
| | - Oliver A Nascimento
- Respiratory Division, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/Unifesp), São Paulo 04023-062, Brazil.
- Pulmonary Rehabilitation Unit, EPM/Unifesp, São Paulo 04023-062, Brazil.
- Faculdade de Medicina São Leopoldo Mandic/Instituto São Leopoldo Mandic, Campinas 13045-755, Brazil.
- Internal Medical Expert at GlaxoSmithKline (GSK), Rio de Janeiro 22783-110, Brazil.
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Sethi S, Kerwin E, Watz H, Ferguson GT, Mroz RM, Segarra R, Molins E, Jarreta D, Garcia Gil E. AMPLIFY: a randomized, Phase III study evaluating the efficacy and safety of aclidinium/formoterol vs monocomponents and tiotropium in patients with moderate-to-very severe symptomatic COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:667-682. [PMID: 30962681 PMCID: PMC6435124 DOI: 10.2147/copd.s189138] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 11/29/2022] Open
Abstract
Background AMPLIFY assessed the efficacy and safety of aclidinium bromide/formoterol fumarate (AB/FF) vs its monocomponents and tiotropium (TIO) in patients with moderate-to-very severe symptomatic COPD (NCT02796677). Methods In this 24-week, Phase III, double-dummy, active-controlled study, symptomatic patients (COPD Assessment Test score ≥10) were randomized to twice-daily AB/FF 400/12 µg, AB 400 µg, or FF 12 µg, or once-daily TIO 18 µg. Co-primary endpoints were change from baseline at week 24 in 1-hour morning post-dose FEV1 (AB/FF vs AB) and in pre-dose (trough) FEV1 (AB/FF vs FF). Non-inferiority of AB vs TIO in pre-dose FEV1 was also an objective. Normalized area under the curve (AUC)0–3/3 h FEV1 and nighttime and early morning symptoms were also assessed. A subgroup participated in a 24-hour serial spirometry sub-study. Results A total of 1,594 patients were randomized; 566 entered the sub-study. At week 24, 1-hour post-dose FEV1 significantly improved with AB/FF vs AB, FF, and TIO (84, 84, and 92 mL; all P<0.0001). AB/FF significantly improved trough FEV1 vs FF (55 mL, P<0.001) and AB was non-inferior to TIO. AB/FF significantly improved AUC0–3/3 h FEV1 vs all comparators (P<0.0001) and provided significant improvements in early morning symptoms vs TIO. The 24-hour spirometry demonstrated significantly greater improvements with AB/FF in AUC12–24/12 h vs all comparators, and in AUC0–24/24 h vs FF or TIO at week 24. Conclusion In patients with moderate-to-very severe symptomatic COPD, twice-daily AB/FF significantly improved lung function vs monocomponents and TIO, and early morning symptom control vs TIO.
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Affiliation(s)
- Sanjay Sethi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA,
| | | | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Robert M Mroz
- Centrum Medycyny Oddechowej, Białystok, Poland.,Medical University of Białystok, Białystok, Poland
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Krishnan S, Ianotti V, Welter J, Gallagher MM, Ndjatou T, Dozor AJ. Bronchodilators, Antibiotics, and Oral Corticosteroids Use in Primary Care for Children With Cough. Glob Pediatr Health 2019; 6:2333794X19831296. [PMID: 30828592 PMCID: PMC6390215 DOI: 10.1177/2333794x19831296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/15/2018] [Revised: 12/10/2018] [Accepted: 12/18/2018] [Indexed: 01/16/2023] Open
Abstract
Real-world management decisions for acute cough in children in primary care
practice are not well understood. This study is an analysis of 560 encounters
for children with cough, 19 days to 18 years of age, seen in a predominantly
suburban academic pediatric practice, over 1 year. Past history, cough duration,
and cough characteristics significantly affected treatment decisions. Children
with cough frequently had a history of preterm birth, allergies, asthma, and
neurological conditions. Most common therapies were bronchodilators,
antibiotics, and oral corticosteroids. Children prescribed antibiotics were
older, more likely to have a wet or productive cough, history of sinusitis,
pneumonia or dysphagia, and longer cough duration. Children prescribed oral
corticosteroids were younger, less likely to be wet or productive and more
likely to have history of asthma or dysphagia. Children prescribed
bronchodilators were more likely to have fever, nasal congestion, and wheezing
and history of previous asthma, pneumonia, or dysphagia.
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Affiliation(s)
| | | | | | | | - Tatiana Ndjatou
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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Bissell K, Ellwood P, Ellwood E, Chiang CY, Marks GB, El Sony A, Asher I, Billo N, Perrin C. Essential Medicines at the National Level: The Global Asthma Network's Essential Asthma Medicines Survey 2014. Int J Environ Res Public Health 2019; 16:E605. [PMID: 30791442 PMCID: PMC6406388 DOI: 10.3390/ijerph16040605] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/01/2019] [Accepted: 02/02/2019] [Indexed: 12/21/2022]
Abstract
Patients with asthma need uninterrupted supplies of affordable, quality-assured essential medicines. However, access in many low- and middle-income countries (LMICs) is limited. The World Health Organization (WHO) Non-Communicable Disease (NCD) Global Action Plan 2013⁻2020 sets an 80% target for essential NCD medicines' availability. Poor access is partly due to medicines not being included on the national Essential Medicines Lists (EML) and/or National Reimbursement Lists (NRL) which guide the provision of free/subsidised medicines. We aimed to determine how many countries have essential asthma medicines on their EML and NRL, which essential asthma medicines, and whether surveys might monitor progress. A cross-sectional survey in 2013⁻2015 of Global Asthma Network principal investigators generated 111/120 (93%) responses-41 high-income countries and territories (HICs); 70 LMICs. Patients in HICs with NRL are best served (91% HICs included ICS (inhaled corticosteroids) and salbutamol). Patients in the 24 (34%) LMICs with no NRL and the 14 (30%) LMICs with an NRL, however no ICS are likely to have very poor access to affordable, quality-assured ICS. Many LMICs do not have essential asthma medicines on their EML or NRL. Technical guidance and advocacy for policy change is required. Improving access to these medicines will improve the health system's capacity to address NCDs.
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Affiliation(s)
- Karen Bissell
- School of Population Health, University of Auckland, Auckland 1023, New Zealand.
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland 1023, New Zealand.
| | - Eamon Ellwood
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland 1023, New Zealand.
| | - Chen-Yuan Chiang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan.
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan.
| | - Guy B Marks
- South Western Sydney Clinical School, University of New South Wales, Sydney 2085, Australia.
| | - Asma El Sony
- The Epidemiological Laboratory (Epi-Lab), for Public Health and Research, Khartoum, Sudan.
| | - Innes Asher
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland 1023, New Zealand.
| | - Nils Billo
- Independent Consultant, 80220 Joensuu, Finland.
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Abstract
INTRODUCTION Chlorine exposure can lead to pulmonary obstruction, reactive airway dysfunction syndrome, acute respiratory distress syndrome and, rarely, death. OBJECTIVE We performed a systematic review of published animal and human data regarding the management of chlorine exposure. METHODS Three databases were searched from 2007 to 2017 using the following keywords "("chlorine gas" OR "chlorine-induced" OR" chlorine-exposed") AND ("therapy" OR "treatment" OR "post-exposure")". Forty-five relevant papers were found: 22 animal studies, 6 reviews, 19 case reports and 1 human randomized controlled study. General management: Once the casualty has been removed from the source of exposure and adequately decontaminated, chlorine-exposed patients should receive supportive care. Humidified oxygen: If dyspnea and hypoxemia are present, humidified oxygen should be administered. Inhaled bronchodilators: The use of nebulized or inhaled bronchodilators to counteract bronchoconstriction is standard therapy, and the combination of ipratropium bromide with beta2-agonists effectively reversed bronchoconstriction, airway irritation and increased airway resistance in experimental studies. Inhaled sodium bicarbonate: In a randomized controlled trial, humidified oxygen, intravenous prednisolone and inhaled salbutamol were compared with nebulized sodium bicarbonate. The only additional benefit of sodium bicarbonate was to increase the forced expiratory volume in one second, 2 and 4 h after administration. Corticosteroids: Dexamethasone 100 mg/kg intraperitoneally (IP) reduced lung edema when given within 1 h of chlorine inhalation and when administered within 6 h significantly decreased (p < 0.01) the leukocyte count in the bronchoalveolar lavage (BAL). As corticosteroids were never given alone in clinical studies, it is impossible to assess whether they had an additional beneficial effect. Antioxidants: An ascorbic acid/deferoxamine combination (equivalent to 100 mg/kg and 15 mg/kg, respectively) was administered intramuscularly 1 h after chlorine exposure, then every 12 h up to 60 h, then as an aerosol, and produced a significant reduction (p < 0.05) in BAL leukocytes and a significant reduction (p < 0.007) in mortality at 72 h. The single clinical case reported was uninterpretable. Sodium nitrite: Sodium nitrite 10 mg/kg intramuscularly (IM), 30 min post-chlorine exposure in mice and rabbits significantly reduced (p < 0.01) the number of leukocytes and the protein concentration in BAL and completely reversed mortality in rabbits and decreased mortality by about 50% in mice. No clinical studies have reported the use of sodium nitrite. Dimethylthiourea: Dimethylthiourea 100 mg/kg IP significantly decreased (p < 0.05) lymphocytes and neutrophils in BAL fluid 24 h after chlorine exposure in experimental studies. No clinical studies have been undertaken. AEOL 10150: Administration of AEOL10150 5 mg/kg IP at 1 h and 9 h post-chlorine exposure reduced significantly the neutrophil (p < 0.001) and macrophage (p < 0.05) bronchoalveolar cell counts. Transient receptor potential vanilloid 4 (TRPV4): IM or IP TRPV4 reduced significantly (p < 0.001) bronchoalveolar neutrophil and macrophage counts to baseline at 24 h. No clinical studies have been performed. Reparixin and triptolide: In experimental studies, triptolide 100-1000 µg/kg IP 1 h post-exposure caused a significant decrease (p < 0.001) in bronchoalveolar neutrophils, whereas reparixin 15 mg/kg IP 1 h post-exposure produced no benefit. Rolipram: Nanoemulsion formulated rolipram administered intramuscularly returned airway resistance to baseline. Rolipram (40%)/poly(lactic-co-glycolic acid) (60%) 0.36 mg/mouse given intramuscularly 1 h post-exposure significantly reduced (p < 0.05) extravascular lung water by 20% at t + 6 h. Prophylactic antibiotics: Studies in patients have failed to demonstrate benefit. Sevoflurane: Sevoflurane has been used in one intubated patient in addition to beta2-agonists. Although the peak inspiratory pressure was decreased after 60 min, the role of sevofluorine is not known. CONCLUSIONS Various therapies seem promising based on animal studies or case reports. However, these recommendations are based on low-level quality data. A systematic list of outcomes to monitor and improve may help to design optimal therapeutic protocols to manage chlorine-exposed patients.
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Affiliation(s)
- Alice Huynh Tuong
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France.,b Population-based Epidemiologic Cohorts Unit , INSERM, UMS011 , Villejuif , France.,c Aging and Chronic Diseases: Epidemiological and Public Health Approaches , INSERM, U1168 , Villejuif , France
| | - Thomas Despréaux
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France.,b Population-based Epidemiologic Cohorts Unit , INSERM, UMS011 , Villejuif , France.,c Aging and Chronic Diseases: Epidemiological and Public Health Approaches , INSERM, U1168 , Villejuif , France
| | - Thomas Loeb
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France
| | - Jérôme Salomon
- d Versailles Saint Quentin-en-Yvelines University , Institut Pasteur, INSERM, UMR 1181 , Paris , France.,e Department of Acute Medicine , CHU PIFO, APHP, Poincaré Hospital , Garches , France
| | - Bruno Mégarbane
- f Department of Medical and Toxicological Critical Care Medicine , APHP, Lariboisière Hospital , Paris , France.,g Paris-Diderot University, INSERM UMR-S 1144 , Paris , France
| | - Alexis Descatha
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France.,b Population-based Epidemiologic Cohorts Unit , INSERM, UMS011 , Villejuif , France.,c Aging and Chronic Diseases: Epidemiological and Public Health Approaches , INSERM, U1168 , Villejuif , France
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Hanania NA, Sethi S, Koltun A, Ward JK, Spanton J, Ng D. Long-term safety and efficacy of formoterol fumarate inhalation solution in patients with moderate-to-severe COPD. Int J Chron Obstruct Pulmon Dis 2018; 14:117-127. [PMID: 30643398 PMCID: PMC6311322 DOI: 10.2147/copd.s173595] [Citation(s) in RCA: 2] [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] [Indexed: 11/23/2022] Open
Abstract
Background Formoterol fumarate inhalation solution (FFIS; Perforomist®) is a long-acting β2-agonist (LABA) marketed in the US as a nebulized COPD maintenance treatment. Because long-term LABA use was associated with a potential increased risk of exacerbation or death in asthma patients, the US Food and Drug Administration (FDA) requested a postmarketing commitment study to evaluate long-term safety in COPD patients. Methods This was a multicenter, randomized, double-blind, placebo-controlled, noninferiority study. Patients (N=1,071; mean age, 62.6 years; 48.5% male; 89.7% white) with moderate-to-severe COPD on stable COPD therapy received FFIS (20 µg; n=541) or placebo (n=530) twice daily. The primary end point was the combined incidence of respiratory death, first COPD-related ER visit, or first COPD exacerbation-related hospitalization during 1 year post randomization. Noninferiority to placebo was concluded if the two-sided 90% CI of the HR of FFIS to placebo was <1.5. Secondary end points included spirometry. Results The planned 1-year treatment period was completed by 520 patients; 551 discontinued prematurely (FFIS: 45.7%; placebo: 57.4%). The median treatment duration was approximately 10 and 7 months for FFIS and placebo, respectively. Among 1,071 randomized patients, 121 had ≥1 primary event (FFIS: 11.8%; placebo: 10.8%). The estimated HR of a primary event with FFIS vs placebo was 0.965 (90% CI: 0.711, 1.308), demonstrating that FFIS was noninferior to placebo. No respiratory deaths were observed in the FFIS group. Adverse events were similar for FFIS vs placebo (patients with ≥1 treatment-emergent adverse events: 374 [69.1%] vs 369 [69.6%], respectively). Compared with placebo, FFIS demonstrated statistically greater improvements from baseline in trough FEV1, FVC, percent predicted FEV1, and patient-reported outcomes (Transition Dyspnea Index). Conclusions Nebulized FFIS was noninferior to placebo with respect to safety in patients with moderate-to-severe COPD. Additionally, fewer treatment withdrawals and larger lung function improvements were observed with FFIS compared with placebo when added to other maintenance COPD therapies.
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Affiliation(s)
- Nicola A Hanania
- Asthma Clinical Research Center, Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sanjay Sethi
- Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Arkady Koltun
- Global Medical Affairs, Mylan Inc., Canonsburg, PA, USA
| | - Jonathan K Ward
- Mylan Global Respiratory Group, Mylan Pharma UK Ltd., Sandwich, Kent, UK,
| | - Jacqui Spanton
- Mylan Global Respiratory Group, Mylan Pharma UK Ltd., Sandwich, Kent, UK,
| | - Dik Ng
- Mylan Global Respiratory Group, Mylan Pharma UK Ltd., Sandwich, Kent, UK,
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49
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Drugs for cough. Med Lett Drugs Ther 2018; 60:206-8. [PMID: 30625123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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50
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Kopel LS, Klings ES, Monuteaux MC, Gaffin JM, Heeney MM, Phipatanakul W. Bronchodilator Use for Acute Chest Syndrome Among Large Pediatric Hospitals in North America. Clin Pediatr (Phila) 2018; 57:1630-1637. [PMID: 30173539 PMCID: PMC6505689 DOI: 10.1177/0009922818796661] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The utility of bronchodilators to treat acute chest syndrome (ACS) in patients with sickle cell disease is unknown. Our objectives were to examine the variability in bronchodilator use for ACS among pediatric hospitals contributing to a large database and to examine the relationship between bronchodilator use and length of stay (LOS) and mortality. Between 2005 and 2011, bronchodilators were used during 6812/11 328 hospitalizations (60.1%) and use varied from 0.0% to 97.0% (median = 46.0%, interquartile range = 37.0% to 74.0%). Median LOS was 4 days, and interquartile range was 2 to 6 days. Bronchodilator use was associated with a 13.2% increase in LOS (95% confidence interval = 9.2% to 17.3%, P < .001). However, in the subgroup with asthma, bronchodilator use was associated with a 17.9% decrease in LOS (95% confidence interval = 1.7% to 31.4%, P = .03). There is wide variability in bronchodilator use for ACS, and it has variable association with LOS, depending on comorbid asthma. Prospective trials are needed to evaluate bronchodilators for ACS.
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Affiliation(s)
| | | | | | | | | | - Wanda Phipatanakul
- Boston Children’s Hospital, Boston, MA, USA,Brigham and Women’s Hospital, Boston, MA, USA
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