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Okamura A, Watanabe M, Kitazono S, Manoshiro H, Kasama E, Takahashi K, Toihata T, Otake R, Kozuki R, Imamura Y, Yamahara Y, Ishizuka N. The Design of and Rationale for the Effect of Perioperative Inhaled Tiotropium for Patients with Chronic Obstructive Pulmonary Disease in Esophageal Cancer Surgery (EPITOPE): an Open-Label, Randomized, Parallel-Group Study. Eur Surg Res 2020; 61:123-129. [PMID: 32248190 DOI: 10.1159/000506512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/14/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pneumonia is one of the most frequently occurring complications after esophagectomy and is associated with increased operative mortality. Chronic obstructive pulmonary disease (COPD) is known to be a risk factor for pulmonary complications and operative mortality. However, in COPD patients preparing for esophagectomy, preventive measures against postoperative pneumonia have not yet been discovered. In this study, we evaluate the effect of perioperative inhaled tiotropium, a long-acting, antimuscarinic bronchodilator used in the management of COPD, on patients with COPD who undergo esophageal cancer surgery. METHODS/DESIGN This study investigates the effect of perioperative inhaled tiotropium on patients with COPD who undergo esophagectomy. It is an open-label, randomized controlled trial conducted in a single center (EPITOPE study). A total of 32 enrolled patients are randomly assigned in a 1:1 ratio to either conventional management or inhalation of tiotropium in addition to the conventional management. Patients included in the intervention group receive tiotropium Respimat 5 μg (two inhalations of 2.5 μg) for at least 2 weeks before the esophagectomy. Following the esophagectomy, tiotropium is re-delivered, starting as early as possible and continuing until the postoperative evaluation (between 30 and 44 days after the operation). The primary outcome is the incidence of pneumonia within 30 days after esophagectomy. Secondary outcomes are the incidence of cardiovascular complications within 30 days after esophagectomy, the incidence of any postoperative complications within 30 days after esophagectomy, pulmonary function (preintervention, preoperative, and postoperative), walking distance in the incremental shuttle walking test (preintervention, preoperative, and postoperative), the incidence of adverse events, and mortality within 30 days after esophagectomy. DISCUSSION The EPITOPE study is the first pilot study on the effects of perioperative inhaled tiotropium on patients with COPD undergoing esophagectomy. After completing this study, we will plan a multicenter RCT with the appropriate outcomes in the future.
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Affiliation(s)
- Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan,
| | - Satoru Kitazono
- Department of Thoracic Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Haruka Manoshiro
- Department of Orthopedic Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Emi Kasama
- Department of Orthopedic Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Keita Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Reiko Otake
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryotaro Kozuki
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuko Yamahara
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Ishizuka
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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He J, Lin JT. A comparison of tiotropium/olodaterol vs tiotropium alone in terms of treatment effect for chronic obstructive pulmonary disease: A meta-analysis. Medicine (Baltimore) 2020; 99:e19789. [PMID: 32311990 PMCID: PMC7440302 DOI: 10.1097/md.0000000000019789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Combinations of long-acting bronchodilators with different mechanisms of action are recommended to improve prognosis and reduce risk of adverse events of chronic obstructive pulmonary disease (COPD). It is unclear whether the new combination therapy with long-acting muscarinic antagonist (LAMA) tiotropium (TIO) and long acting beta-agonists (LABA) olodaterol (OLO) was superior to tiotropium alone. METHODS We measured the efficacy of the TIO/OLO combination vsTIO alone for COPD patients based on electronic databases up to February 2019. After rigorous quality review, data was extracted from eligible trials. All the main outcomes were pooled analysis using RevMan software. RESULTS A total of 6 randomized controlled trials (RCTs) were identified. The pooled results of our meta-analysis demonstrated that FEV1 [MD = 0.03, 95% CI (-0.01,0.07), P = .18], FVC [MD = -0.03, 95%CI (-0.06,0.00), P = .09] and FEV1%pred [MD = 0.35, 95%CI (-0.30, 0.99), P = .29] all showed no significant difference between the 2 groups. The overall incidence of adverse effects (AEs) [OR = 1.01,95%CI (0.93,1.09), P = .87] and serious AEs [OR = 1.04,95% CI (0.82, 1.32), P = .72] in the combination group was similar to that of the TIO alone group, without statistical significance. CONCLUSION These studies reported that the TIO/OLO combination did not show superior effects than tiotropium alone for COPD. Additionally, both therapies were well tolerated.
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Satia I, Farooqi MAM, Cusack R, Matsuoka M, Yanqing X, Kurmi O, O’Byrne PM, Killian KJ. The contribution of FEV 1 and airflow limitation on the intensity of dyspnea and leg effort during exercise. Insights from a real-world cohort. Physiol Rep 2020; 8:e14415. [PMID: 32323482 PMCID: PMC7177171 DOI: 10.14814/phy2.14415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/14/2020] [Accepted: 03/16/2020] [Indexed: 11/24/2022] Open
Abstract
RATIONALE The effort required to cycle and breathe intensify as power increases during incremental exercise. It is currently unclear how changes in FEV1 in the presence or absence of airflow limitation) impacts the intensity of dyspnea and leg effort. This is clinically important as the improvement in FEV1 is often the target for improving dyspnea. OBJECTIVES To investigate the relationship between dyspnea (D), leg effort, power (P), and FEV1 with and without airflow limitation using direct psychophysical scaling performed during incremental exercise testing to symptom limited capacity. METHODS Retrospective analysis of consecutive patients over the age of 35 referred for cardio-pulmonary exercise testing at McMaster University Medical Centre from 1988-2012.The modified Borg scale was used to measure dyspnea throughout incremental exercise testing. MEASUREMENTS AND RESULTS 38,788 patients were included in the analysis [Mean Age 58.6 years (SD ±11.8), Males 61%, BMI 28.1 kg/m2 (SD ±5.1), FEV1 was 2.7 L (SD ±0.85), 95% predicted (SD ±20.4), FVC 3.4 L (SD ± 1.0), 94% predicted (SD ±17.0)], and 10.9% had airflow limitation (AL, FEV1 /FVC < 70%). In a nonlinear regression analysis, the intensity of dyspnea increased in a positively accelerating manner with power and as the FEV1 % predicted decreased: Dyspnea = 0.06 * Power1.03 * FEV1 %Pred-0.66 (r = .63). The intensity of leg effort increased with power and declining quadricep strength and FEV1% predicted: Leg Effort = 0.06 * Power1.22 * Quad-0.56 *FEV1 %Pred-0.39 (r = .73). There was no independent effect of AL on dyspnea of leg effort. CONCLUSION Power, quadriceps strength and FEV1 are the dominant factors contributing to dyspnea and leg effort, irrespective of the degree of airflow limitation.
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Affiliation(s)
- Imran Satia
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
- Firestone Institute for Respiratory HealthSt Joseph’s HealthcareHamiltonONCanada
- Division of Infection, Immunity and Respiratory MedicineManchester Academic Health Science CentreUniversity of ManchesterManchesterUK
| | - Mohammad Abdul Malik Farooqi
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
- Firestone Institute for Respiratory HealthSt Joseph’s HealthcareHamiltonONCanada
| | - Ruth Cusack
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
| | - Masanobu Matsuoka
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
| | - Xie Yanqing
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
| | - Om Kurmi
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
| | - Paul M. O’Byrne
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
- Firestone Institute for Respiratory HealthSt Joseph’s HealthcareHamiltonONCanada
| | - Kieran J. Killian
- Division of RespirologyDepartment of MedicineMcMaster UniversityHamiltonONCanada
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Hillas G, Papaporfyriou A, Dimakou K, Papaioannou AI. Pharmacological treatment of stable COPD: need for a simplified approach. Postgrad Med 2020; 132:126-131. [DOI: 10.1080/00325481.2019.1706996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- G. Hillas
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. Papaporfyriou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
| | - K. Dimakou
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. I. Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
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Siler TM, Moran EJ, Barnes CN, Crater GD. Safety and Efficacy of Revefenacin and Formoterol in Sequence and Combination via a Standard Jet Nebulizer in Patients with Chronic Obstructive Pulmonary Disease: A Phase 3b, Randomized, 42-Day Study. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 7:99-106. [PMID: 32324981 DOI: 10.15326/jcopdf.7.2.2019.0154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Although no nebulized, dual mechanism, long-acting bronchodilator is currently marketed, with the approval of once-daily long-acting muscarinic antagonist (LAMA) revefenacinefenacin, it is theoretically possible to deliver a LAMA and long-acting beta2-agonist via standard jet nebulizer. The primary and secondary objectives of our study were to characterize the safety profile of revefenacin administered sequentially before or in combination with formoterol, via standard jet nebulizer in patients with moderate to very severe chronic obstructive pulmonary disease (COPD). In this randomized, double-blind, 42-day trial (NCT03573817), patients received revenacin 175 µg (n=63) or placebo (n=59), followed by formoterol 20 µg in the morning and formoterol alone in the evening formoterol 21 days via standard jet nebulizer (sequential administration). For another 21 days, revefenacin/placebo and formoterol, were administered as mixed solutions via single nebulization in the morning (combined administration), and formoterol alone in the evening. The adverse events' (AEs) incidence was higher in the placebo + formoterol arms (11%-12%) than in the revefenacin + formoterol arms (5%-8%). The most common AEs were worsening/exacerbation of COPD, cough, and dizziness. There were no serious AEs or deaths reported in any arm. The least squares mean in trough forced expiratory volume in 1 second (FEV1) versus baseline was higher in the revefenacin + formoterol arms (116-157 mL) than in the placebo + formoterol arms (35-53 mL). Revefenacin had a safety profile similar to formoterol alone when delivered sequentially or combined. Trough FEV1 was similar when revefenacin was delivered sequentially or combined with formoterol, with revefenacin providing an additional 81-104 mL improvements over formoterol alone.
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Affiliation(s)
| | - Edmund J Moran
- Theravance Biopharma US, Inc., South San Francisco, California
| | - Chris N Barnes
- Theravance Biopharma US, Inc., South San Francisco, California
| | - Glenn D Crater
- Theravance Biopharma US, Inc., South San Francisco, California
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Abstract
:
Triple inhaled therapy for Chronic Obstructive Pulmonary Disease (COPD) includes an
inhaled corticosteroid (ICS), a long-acting b2-agonist (LABA) and a long-acting muscarinic
antagonist (LAMA) taken in combination. Triple therapy is recommended by the Global Initiative for
Chronic Obstructive Lung Disease (GOLD) for patients who experience recurrent exacerbations
despite treatment with either a dual bronchodilator or LABA/ICS combination. There is consistent
evidence that the LABA/LAMA/ICS combination has significantly greater effects on trough FEV1,
symptoms, quality of life, and exercise performance compared to comparator treatments.
:
The role of triple therapy in reducing exacerbations in COPD patients is debatable, but recent trials
have revealed some intriguing insights.
:
Three pivotal studies, namely TRILOGY, TRINITY and TRIBUTE have been conducted to evaluate
the safety and efficacy of extrafine Beclomethasone/Formoterol Fumarate/Glycopyrronium Bromide
(BDP/FF/GB) versus different treatment options for COPD. Extrafine BDP/FF/GB has been
compared to an ICS/LABA (BDP/FF) combination in the TRILOGY study, to a LAMA
monotherapy (Tiotropium-TIO) and an extemporary triple combination of ICS/LABA + LAMA
(BDP/FF + TIO) in the TRINITY study, and to one inhalation of LABA/LAMA per day (Indacaterol/
Glycopyrronium - IND/GLY) in the TRIBUTE study.
:
Another triple therapy with Fluticasone Furoate/Umeclidinium/Vilanterol (FF/UMEC/VI) was
recently tested in two further studies that included patients with COPD. The FULFIL study compared
the efficacy of the triple FF/UMEC/VI therapy to the ICS/LABA association budesonide/formoterol,
while the IMPACT study compared the rate of moderate and severe exacerbations between singleinhaler
FF/UMEC/VI and single-inhaler FF/VI or UMEC/VI.
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Ray R, Hahn B, Stanford RH, White J, Essoi B, Hunter AG. Classification of Patients with COPD on LAMA Monotherapy Using the GOLD Criteria: Analysis of a Claims-Linked Patient Survey Study. Pulm Ther 2019; 5:191-200. [PMID: 32026409 PMCID: PMC6967324 DOI: 10.1007/s41030-019-00099-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION To address the burden of chronic obstructive pulmonary disease (COPD), the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends treatment according to classification of patients by symptom severity and exacerbation risk. This post hoc analysis of a previously reported claims-linked, cross-sectional survey [study 205862 (HO-16-16642)] classified patients with COPD receiving long-acting muscarinic antagonist (LAMA) monotherapy based on the GOLD 2017 categories. METHODS Eligible patients who were ≥ 40 years of age, with ≥ 2 claims with International Classification of Diseases-10th Revision-Clinical Modification COPD diagnosis codes J40-J44 ≥ 30 days apart during the 12-month baseline period, and ≥ 2 claims for LAMA monotherapy in the 6 months prior to identification, were identified using claims data from the Optum Research Database. Patients completed a survey assessing modified Medical Research Council (mMRC) Dyspnea Scale and COPD Assessment Test (CAT) scores and demographics; clinical characteristics were assessed from claims and survey data, while exacerbation history was assessed from claims data. GOLD symptom severity classifications were low (groups A and C) for patients with low scores on both the CAT and mMRC scales (scores of < 10 and 0-1, respectively), and high (groups B and D) for patients with high scores on either scale (scores of ≥ 10 and 2-4, respectively). RESULTS Of 433 patients included, 85.5% reported a CAT total score ≥ 10, and 45.5% reported mMRC grades 2-4. During the baseline period, 63.7% of patients had ≤ 1 moderate and 0 severe (hospitalized) exacerbations, and 36.3% had ≥ 1 severe or ≥ 2 moderate exacerbation(s). The proportions of patients with each GOLD classification were: A: 9.0%; B: 54.7%; C: 4.6%; D: 31.6%. CONCLUSIONS In this population, over 85% of LAMA monotherapy users have symptoms and/or exacerbation risk that may necessitate therapy escalation according to 2017 GOLD guidelines. FUNDING GlaxoSmithKline [study 205862 (HO-16-16642)].
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Affiliation(s)
- Riju Ray
- US Medical Affairs, GSK, Research Triangle Park, NC, USA
| | - Beth Hahn
- US Value Evidence and Outcomes, GSK, Research Triangle Park, NC, USA.
| | | | - John White
- Health Economics and Outcomes Research, Optum, Eden Prairie, MN, USA
| | - Breanna Essoi
- Health Economics and Outcomes Research, Optum, Eden Prairie, MN, USA
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Rogliani P, Matera MG, Ritondo BL, De Guido I, Puxeddu E, Cazzola M, Calzetta L. Efficacy and cardiovascular safety profile of dual bronchodilation therapy in chronic obstructive pulmonary disease: A bidimensional comparative analysis across fixed-dose combinations. Pulm Pharmacol Ther 2019; 59:101841. [DOI: 10.1016/j.pupt.2019.101841] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/21/2019] [Accepted: 09/10/2019] [Indexed: 12/12/2022]
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Maltais F, Bjermer L, Kerwin EM, Jones PW, Watkins ML, Tombs L, Naya IP, Boucot IH, Lipson DA, Compton C, Vahdati-Bolouri M, Vogelmeier CF. Efficacy of umeclidinium/vilanterol versus umeclidinium and salmeterol monotherapies in symptomatic patients with COPD not receiving inhaled corticosteroids: the EMAX randomised trial. Respir Res 2019; 20:238. [PMID: 31666084 PMCID: PMC6821007 DOI: 10.1186/s12931-019-1193-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/20/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Prospective evidence is lacking regarding incremental benefits of long-acting dual- versus mono-bronchodilation in improving symptoms and preventing short-term disease worsening/treatment failure in low exacerbation risk patients with chronic obstructive pulmonary disease (COPD) not receiving inhaled corticosteroids. METHODS The 24-week, double-blind, double-dummy, parallel-group Early MAXimisation of bronchodilation for improving COPD stability (EMAX) trial randomised patients at low exacerbation risk not receiving inhaled corticosteroids, to umeclidinium/vilanterol 62.5/25 μg once-daily, umeclidinium 62.5 μg once-daily or salmeterol 50 μg twice-daily. The primary endpoint was trough forced expiratory volume in 1 s (FEV1) at Week 24. The study was also powered for the secondary endpoint of Transition Dyspnoea Index at Week 24. Other efficacy assessments included spirometry, symptoms, heath status and short-term disease worsening measured by the composite endpoint of clinically important deterioration using three definitions. RESULTS Change from baseline in trough FEV1 at Week 24 was 66 mL (95% confidence interval [CI]: 43, 89) and 141 mL (95% CI: 118, 164) greater with umeclidinium/vilanterol versus umeclidinium and salmeterol, respectively (both p < 0.001). Umeclidinium/vilanterol demonstrated consistent improvements in Transition Dyspnoea Index versus both monotherapies at Week 24 (vs umeclidinium: 0.37 [95% CI: 0.06, 0.68], p = 0.018; vs salmeterol: 0.45 [95% CI: 0.15, 0.76], p = 0.004) and all other symptom measures at all time points. Regardless of the clinically important deterioration definition considered, umeclidinium/vilanterol significantly reduced the risk of a first clinically important deterioration compared with umeclidinium (by 16-25% [p < 0.01]) and salmeterol (by 26-41% [p < 0.001]). Safety profiles were similar between treatments. CONCLUSIONS Umeclidinium/vilanterol consistently provides early and sustained improvements in lung function and symptoms and reduces the risk of deterioration/treatment failure versus umeclidinium or salmeterol in symptomatic patients with low exacerbation risk not receiving inhaled corticosteroids. These findings suggest a potential for early use of dual bronchodilators to help optimise therapy in this patient group.
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Affiliation(s)
- François Maltais
- Centre de Pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada.
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Paul W Jones
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Michael L Watkins
- Respiratory Research and Development, GSK, Research Triangle Park, NC, USA
| | - Lee Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Ian P Naya
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | | | - David A Lipson
- Respiratory Research and Development, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Compton
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Mitra Vahdati-Bolouri
- Respiratory Discovery Medicine, Respiratory Research and Development, GSK, Stevenage, Hertfordshire, UK
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Germany, Member of the German Center for Lung Research (DZL), Marburg, Germany
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Struß N, Bauersachs J, Welte T, Hohlfeld JM. Left heart function in COPD : Impact of lung deflation. Herz 2019; 44:477-482. [PMID: 31187193 DOI: 10.1007/s00059-019-4816-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) primarily affects the lungs; however, cardiovascular conditions are among the most common extrapulmonary comorbidities. Besides shared risk factors such as cigarette smoking, pathophysiological connections between the lung and the heart have been identified as mediators of reduced cardiac output. Recent research has focused on hyperinflation of the lung as a pulmonary cause for heart dysfunction. Hyperinflation is a typical lung abnormality seen in COPD; it is characterized by increased residual volume, intrathoracic gas volume, and total lung capacity while vital capacity is decreased. The degree of hyperinflation with airway obstruction is inversely related to left ventricular filling, stroke volume, and cardiac output. The underlying mechanisms are assumed to be compression of the pulmonary veins and thus reduced preload of the left heart as well as decreased pulmonary microvascular blood flow due to compression of the pulmonary vasculature. Treatment with a dual bronchodilator antagonizes this detrimental lung-heart unbalance effectively: Pulmonary blood flow, left ventricular end-diastolic volume, and stroke volume increase in COPD patients without cardiac abnormalities. Similar effects, yet less pronounced, were reported with single bronchodilator therapy. Future work needs to investigate whether these promising findings can be reproduced in COPD patients with cardiovascular diseases.
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Affiliation(s)
- N Struß
- Bereich Atemwegsforschung, Fraunhofer-Institut für Toxikologie und Experimentelle Medizin ITEM, Feodor-Lynen-Straße 15, 30625, Hannover, Germany
| | - J Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - T Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung, Hannover, Germany
| | - J M Hohlfeld
- Bereich Atemwegsforschung, Fraunhofer-Institut für Toxikologie und Experimentelle Medizin ITEM, Feodor-Lynen-Straße 15, 30625, Hannover, Germany. .,Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany. .,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung, Hannover, Germany.
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Barrecheguren M, Miravitlles M. COUNTERPOINT: Should LAMA/LABA Combination Therapy Be Used as Initial Maintenance Treatment for COPD? No. Chest 2019; 154:749-751. [PMID: 30290926 DOI: 10.1016/j.chest.2018.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
- Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
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Roche N, Aguilaniu B, Zhi Li P, Hess D. Trends over time in COPD treatment choices by respiratory physicians: An analysis from the COLIBRI-COPD French cohort. Respir Med 2019; 156:8-14. [PMID: 31374262 DOI: 10.1016/j.rmed.2019.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Over the last decade, new evidence and many guidelines have been published on COPD pharmacological treatments; prescriptions are often not in accordance with guidelines. MATERIALS AND METHODS Trends in physician treatment choices from February 2012 to November 2018 (Feb.2012/Nov.2018) were analyzed using data from COPD patients (spirometry-confirmed diagnosis) included in the COLIBRI-COPD cohort. Inhaled drug treatments (short- or long-acting β2-agonist [SABA or LABA], short- or long-acting anticholinergic [SAMA or LAMA], or corticosteroid [ICS]) were classified into 5 treatment categories: "No initial maintenance treatment (IMT)" (untreated, or only SAMA or SABA); "1 long-acting bronchodilator (LABD)" (LABA or LAMA); "2 LABDs" (LABA + LAMA); "1 LABD + ICS" (LABA or LAMA + ICS); "2 LABDs + ICS" (LABA + LAMA + ICS). For the purpose of the study, 4 periods were defined to achieve balanced samples (T1-T4). RESULTS Data from 4537 patients were collected. Over time, 3 major changes were observed: (1) an increase in treatment category "No IMT", mostly for GOLD 1 or GOLD A categories (GOLD A: from 19.1% at T1 to 41.2% at T4); (2) an increase in treatment category "2 LABDs" for GOLD 2 to 4 and GOLD A to D categories (GOLD B: from 15.4% to 29.7%); (3) a decrease in ICS use ("1 LABD + ICS" or "2 LABDs + ICS"), mostly for GOLD 1 to 3 and GOLD A categories (GOLD A, 2 LABDs + ICS: from 35.3% to 11.1%). CONCLUSION Changes over time in therapeutic profiles suggest that new evidence from scientific publications and recommendations may have had a rapid impact on clinical practice.
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Affiliation(s)
- Nicolas Roche
- Service de Pneumologie, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, AP-HP and Université Paris Descartes (UMR1016, Institut Cochin), Sorbonne Paris Cite, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Bernard Aguilaniu
- Programme Colibri, Association pour la complémentarité des connaissances et des pratiques de la pneumologie (aCCPP), 19 avenue Marcelin Berthelot, 38100, Grenoble, France; Université Grenoble Alpes, Faculté de médecine et pharmacie, 23 Avenue Maquis du Grésivaudan, 38700, La Tronche, France.
| | - Pei Zhi Li
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, McGill University, 5252, boul. de Maisonneuve Ouest, Montreal, QC H4a 3s5, Canada.
| | - David Hess
- Programme Colibri, Association pour la complémentarité des connaissances et des pratiques de la pneumologie (aCCPP), 19 avenue Marcelin Berthelot, 38100, Grenoble, France.
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Muro S, Yoshisue H, Kostikas K, Olsson P, Gupta P, Wedzicha JA. Indacaterol/glycopyrronium versus tiotropium or glycopyrronium in long-acting bronchodilator-naïve COPD patients: A pooled analysis. Respirology 2019; 25:393-400. [PMID: 31339215 PMCID: PMC7155057 DOI: 10.1111/resp.13651] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/27/2019] [Accepted: 06/25/2019] [Indexed: 12/14/2022]
Abstract
Background and objective Indacaterol/glycopyrronium (IND/GLY) 110/50 μg once daily (q.d.) has demonstrated greater improvements in lung function, patient‐reported outcomes and lower exacerbation rates versus mono long‐acting muscarinic antagonists (LAMA) in chronic obstructive pulmonary disease (COPD) patients. However, data are limited on initial treatment with IND/GLY 110/50 μg q.d. versus mono LAMA in COPD patients, not previously on maintenance treatment with long‐acting bronchodilators (LABD). Methods A pooled analysis of ARISE, SHINE and SPARK trials was conducted to evaluate the efficacy of IND/GLY 110/50 μg q.d. versus open‐label (OL) tiotropium (TIO) 18 μg q.d. and GLY 50 μg q.d. in COPD patients, not on maintenance treatment with LABD at study entry (LABD‐naïve). Efficacy was assessed after 24/26 weeks of treatment. Results In total, 998 LABD‐naïve patients were included (IND/GLY: 353; OL TIO: 328; GLY: 317). Patients treated with IND/GLY 110/50 μg q.d. experienced greater improvements in trough forced expiratory volume in 1 s (FEV1) versus OL TIO 18 μg q.d. (least squares mean treatment difference (Δ): 0.086 L) and GLY 50 μg q.d. (Δ: 0.080 L) after 24/26 weeks. Improvements in electronic diary (eDiary) symptom scores, transition dyspnoea index (TDI) focal score, St George's Respiratory Questionnaire (SGRQ) total score and rescue medication use were also greater with IND/GLY versus OL TIO and GLY. Greater proportion of patients achieved minimal clinically important difference in trough FEV1, TDI and SGRQ with IND/GLY versus OL TIO and GLY. Conclusion LABD‐naïve patients treated with IND/GLY 110/50 μg q.d. achieved improvements in lung function, daily symptoms, dyspnoea, health‐related quality of life and rescue medication use versus those who received single LAMA.
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Affiliation(s)
- Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Nara, Japan
| | | | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina Medical School, Ioannina, Greece
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Kistemaker LEM, Elzinga CRS, Tautermann CS, Pieper MP, Seeliger D, Alikhil S, Schmidt M, Meurs H, Gosens R. Second M 3 muscarinic receptor binding site contributes to bronchoprotection by tiotropium. Br J Pharmacol 2019; 176:2864-2876. [PMID: 31077341 DOI: 10.1111/bph.14707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 04/16/2019] [Accepted: 04/29/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND PURPOSE The bronchodilator tiotropium binds not only to its main binding site on the M3 muscarinic receptor but also to an allosteric site. Here, we have investigated the functional relevance of this allosteric binding and the potential contribution of this behaviour to interactions with long-acting β-adrenoceptor agonists, as combination therapy with anticholinergic agents and β-adrenoceptor agonists improves lung function in chronic obstructive pulmonary disease. EXPERIMENTAL APPROACH ACh, tiotropium, and atropine binding to M3 receptors were modelled using molecular dynamics simulations. Contractions of bovine and human tracheal smooth muscle strips were studied. KEY RESULTS Molecular dynamics simulation revealed extracellular vestibule binding of tiotropium, and not atropine, to M3 receptors as a secondary low affinity binding site, preventing ACh entry into the orthosteric binding pocket. This resulted in a low (allosteric binding) and high (orthosteric binding) functional affinity of tiotropium in protecting against methacholine-induced contractions of airway smooth muscle, which was not observed for atropine and glycopyrrolate. Moreover, antagonism by tiotropium was insurmountable in nature. This behaviour facilitated functional interactions of tiotropium with the β-agonist olodaterol, which synergistically enhanced bronchoprotective effects of tiotropium. This was not seen for glycopyrrolate and olodaterol or indacaterol but was mimicked by the interaction of tiotropium and forskolin, indicating no direct β-adrenoceptor-M3 receptor crosstalk in this effect. CONCLUSIONS AND IMPLICATIONS We propose that tiotropium has two binding sites at the M3 receptor that prevent ACh action, which, together with slow dissociation kinetics, may contribute to insurmountable antagonism and enhanced functional interactions with β-adrenoceptor agonists.
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Affiliation(s)
- Loes E M Kistemaker
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carolina R S Elzinga
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christofer S Tautermann
- Department of Medicinal Chemistry, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Michael P Pieper
- Immunology and Respiratory Disease Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Daniel Seeliger
- Department of Medicinal Chemistry, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Suraya Alikhil
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martina Schmidt
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Herman Meurs
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud Gosens
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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65
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Strange C, Walker V, DePietro M, Tong J, Kurlander J, Carlyle M, Millette LA, Wittbrodt E. Patient-reported outcomes of dual bronchodilator fixed-dose combination versus bronchodilator monotherapy in individuals with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:1377-1388. [PMID: 31303751 PMCID: PMC6612016 DOI: 10.2147/copd.s194856] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background: This study compared real-world patient-reported outcomes (PROs) measured by the Clinical COPD Questionnaire (CCQ), the London Chest Activities of Daily Living (LCADL) scale, and the Work Productivity and Activity Impairment (WPAI) questionnaire between individuals with COPD initiating LAMA/LABA fixed-dose combination (FDC) dual therapy versus either long-acting muscarinic antagonist (LAMA) or long-acting beta2-agonist (LABA) monotherapy. Methods: Individuals with COPD aged ≥40 years initiating a LAMA/LABA FDC dual therapy or a LAMA or LABA monotherapy (index date = first prescription date) between January 1, 2016 and December 31, 2016 were identified from a large US administrative claims database. Individuals were excluded if they were prescribed an inhaled corticosteroid (ICS) or ICS/LABA two months prior to the index date or were diagnosed with cystic fibrosis, idiopathic pulmonary fibrosis, or asthma. The cohorts were propensity score matched (PSM) 1:1 for COPD severity using baseline measures. Each participant completed a survey. Results: Surveys were completed by 399 participants in the dual therapy cohort, and 718 participants in the monotherapy cohort. Following PSM, 379 participants remained in each cohort for analysis (monotherapy: 369 LAMA and 10 LABA). The dual therapy cohort reported fewer COPD-related symptoms (CCQ symptom score 2.75 vs 2.97, respectively, P=0.023), and, fewer limitations in leisure activities (LCADL leisure score 4.78 vs 5.17, respectively, P=0.021) versus the monotherapy cohort. No significant differences were found in the WPAI. A greater percentage of participants in the dual therapy cohort stayed on index therapy (63.1%) when compared with the monotherapy cohort (30.3%, P<0.0001). Conclusions: Only 30% of the participants prescribed monotherapy, usually with a LAMA, remained on index therapy alone at the time of survey administration. In the dual therapy cohort, 63% of the participants remained on the index medication and had fewer COPD-related symptoms and fewer limitations in leisure activities compared with participants in the monotherapy cohort.
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Affiliation(s)
- Charlie Strange
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Valery Walker
- Health Economics and Outcomes Research, Optum, Inc., Eden Prairie, MN, USA
| | | | - Junliang Tong
- Health Economics and Outcomes Research, Optum, Inc., Eden Prairie, MN, USA
| | - Jonathan Kurlander
- Health Economics and Outcomes Research, Optum, Inc., Eden Prairie, MN, USA
| | - Maureen Carlyle
- Health Economics and Outcomes Research, Optum, Inc., Eden Prairie, MN, USA
| | | | - Eric Wittbrodt
- Health Economics and Outcomes Research, AstraZeneca, Wilmington, DE, USA
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D'Urzo A, Chapman KR, Donohue JF, Kardos P, Maleki-Yazdi MR, Price D. Inhaler Devices for Delivery of LABA/LAMA Fixed-Dose Combinations in Patients with COPD. Pulm Ther 2019; 5:23-41. [PMID: 32026426 PMCID: PMC6967354 DOI: 10.1007/s41030-019-0090-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Indexed: 02/07/2023] Open
Abstract
Inhaled fixed-dose combinations (FDCs) of a long-acting β-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) have become the cornerstone for the maintenance treatment of symptomatic COPD patients. In this regard, global COPD treatment guidelines have recognized the importance of inhaler devices as integral contributors to the effectiveness of LABA/LAMA FDCs and recommend regular assessment of inhaler device use by the patients in order to improve long-term clinical outcomes. Optimal disease control is also highly dependent upon patient preferences and adherence to inhaler devices. This review objectively examines and compares the major inhaler devices used to deliver different LABA/LAMA FDCs, discusses the inhaler device characteristics that determine drug deposition in the airways, real-life preference for inhaler devices, and handling of inhaler devices that impact the results of the long-term management of COPD. The introduction of new LABA/LAMA FDCs, new inhaler devices, and more clinical studies have created confusion among physicians in choosing the optimal inhaled therapy for COPD patients; in this context, this review attempts to provide an evidence-based framework for informed decision-making with a particular focus on the inhaler devices.Funding. The preparation of this manuscript was funded by Novartis Pharma AG.
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Affiliation(s)
- Anthony D'Urzo
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Kenneth R Chapman
- Asthma and Airway Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - James F Donohue
- Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Peter Kardos
- Group Practice and Centre for Allergy, Respiratory and Sleep Medicine, Red Cross Maingau Hospital, Frankfurt, Germany
| | - M Reza Maleki-Yazdi
- Division of Respiratory Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore, Singapore
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67
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Hahn B, Stanford RH, Goolsby Hunter A, Essoi B, White J, Ray R. Patient-Reported Burden of Illness in a Prevalent COPD Population Treated with Long-Acting Muscarinic Antagonist Monotherapy: A Claims-Linked Patient Survey Study. Pulm Ther 2019; 5:69-80. [PMID: 32026428 PMCID: PMC6967076 DOI: 10.1007/s41030-019-0091-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Symptom burden in inadequately controlled chronic obstructive pulmonary disease (COPD) considerably impacts quality of life, healthcare resource utilization (HCRU) and associated costs. This claims-linked cross-sectional survey study assessed symptom burden and HCRU among a prevalent population of COPD patients prescribed long-acting muscarinic antagonist (LAMA) monotherapy. METHODS Patients were identified using claims data from the Optum Research Database. Eligible patients were aged ≥ 40 years with 12 months' continuous enrollment in a US health plan, ≥ 2 medical claims containing COPD diagnosis codes ≥ 30 days apart, and ≥ 2 claims for LAMA monotherapy in the latter half of the 12-month sample identification period. Patients were mailed a cross-sectional survey assessing patient-reported outcomes (PROs) [COPD assessment test (CAT) and modified medical research council dyspnea scale (mMRC)], clinical characteristics, smoking history, and demographics. Patients also completed the Exacerbations of Chronic Pulmonary Disease Tool (EXACT-PRO) daily diary for 7 days. HCRU was assessed from claims data. RESULTS The study included 433 patients with a self-reported healthcare provider COPD diagnosis, and both claims-based and self-reported LAMA monotherapy treatment (mean age 71.0 years; 59.8% female). Most patients (85.5%) reported a high symptom burden (CAT score ≥ 10), 45.5% had high levels of dyspnea (mMRC grade ≥ 2), and 64.4% reported more severe daily symptoms by the EXACT-PRO. Most patients (71.6%) reported high scores on ≥ 2 PROs. More patients with high symptom burden had COPD-related emergency department visits than those with lower disease burden (27.6% vs 12.7%, P = 0.012). CONCLUSIONS In conclusion, a large proportion of patients with COPD receiving LAMA monotherapy experienced a high symptom burden and may benefit from therapy escalation. Healthcare professionals can use validated PROs to help them assess symptom burden. FUNDING GlaxoSmithKline (GSK study number: 205862).
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Affiliation(s)
- Beth Hahn
- US Value Evidence and Outcomes, GSK, 5 Moore Drive, Research Triangle Park, NC, 27709-3398, USA.
| | - Richard H Stanford
- US Value Evidence and Outcomes, GSK, 5 Moore Drive, Research Triangle Park, NC, 27709-3398, USA
| | - Alyssa Goolsby Hunter
- Health Economics and Outcomes Research, Optum, 11000 Optum Circle, Eden Prairie, MN, 55344, USA
| | - Breanna Essoi
- Health Economics and Outcomes Research, Optum, 11000 Optum Circle, Eden Prairie, MN, 55344, USA
| | - John White
- Health Economics and Outcomes Research, Optum, 11000 Optum Circle, Eden Prairie, MN, 55344, USA
| | - Riju Ray
- US Medical Affairs, GSK, 5 Moore Drive, Research Triangle Park, NC, 27709-3398, USA
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Dolovich MB, Kuttler A, Dimke TJ, Usmani OS. Biophysical model to predict lung delivery from a dual bronchodilator dry-powder inhaler. INTERNATIONAL JOURNAL OF PHARMACEUTICS-X 2019; 1:100018. [PMID: 31517283 PMCID: PMC6733285 DOI: 10.1016/j.ijpx.2019.100018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/24/2019] [Accepted: 05/27/2019] [Indexed: 11/30/2022]
Abstract
A biophysical lung model was designed to predict inhaled drug deposition in patients with obstructive airway disease, and quantitatively investigate sources of deposition variability. Different mouth-throat anatomies at varying simulated inhalation flows were used to calculate the lung dose of indacaterol/glycopyrronium [IND/GLY] 110/50 µg (QVA149) from the dry-powder inhaler Breezhaler®. Sources of variability in lung dose were studied using computational fluid dynamics, supported by aerosol particle sizing measurements, particle image velocimetry and computed tomography. Anatomical differences in mouth-throat geometries were identified as a major source of inter-subject variability in lung deposition. Lung dose was similar across inhalation flows of 30–120 L/min with a slight drop in calculated delivery at high inspiratory flows. Delivery was relatively unaffected by inhaler inclination angle. The delivered lung dose of the fixed-dose combination IND/GLY matched well with corresponding monotherapy doses. This biophysical model indicates low extra-thoracic drug loss and consistent lung delivery of IND/GLY, independent of inhalation flows. This is an important finding for patients across various ages and lung disease severities. The model provides a quantitative, mechanistic simulation of inhaled therapies that could provide a test system for estimating drug delivery to the lung and complement traditional clinical studies.
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Key Words
- AIT, Alberta idealised throat
- APSD, aerodynamic particle size distribution
- CFD, computational fluid dynamics
- COPD, chronic obstructive pulmonary disease
- CT, computed tomography
- Chronic obstructive pulmonary disease
- Computational fluid dynamics
- DPI, dry powder inhaler
- Dry powder inhaler
- FDC, fixed-dose combination
- GLY, glycopyrronium
- HRCT, high-resolution computed tomography
- IFR, inspiratory flow rate
- IND, indacaterol
- Inhaler devices
- Lung deposition
- MMAD, mass median aerodynamic diameter
- NGI, Next Generation Impactor
- PIV, particle image velocimetry
- USP/Ph. Eur, European Union Pharmacopoeias
- pMDI, pressurised metered dose inhaler
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Affiliation(s)
- Myrna B Dolovich
- Department of Medicine, Division of Respirology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
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69
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Hanania NA, O'Donnell DE. Activity-related dyspnea in chronic obstructive pulmonary disease: physical and psychological consequences, unmet needs, and future directions. Int J Chron Obstruct Pulmon Dis 2019; 14:1127-1138. [PMID: 31213793 PMCID: PMC6538882 DOI: 10.2147/copd.s188141] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 04/01/2019] [Indexed: 12/27/2022] Open
Abstract
Dyspnea is a distressing, debilitating, and near-ubiquitous symptom affecting patients with COPD. In addition to the functional consequences of dyspnea, which include activity limitation and reduced exercise tolerance, it is important to consider its psychological impact on patients with COPD, such as onset of depression or anxiety. Moreover, the anticipation of dyspnea itself can have a significant effect on patients' emotions and behavior, with patients frequently self-limiting physical activity to avoid what has become the hallmark symptom of COPD. Dyspnea is, therefore, a key target for COPD treatments. Pharmacologic treatments can optimize respiratory mechanics, provide symptom relief, and reduce patients' increased inspiratory neural drive to breathe. However, it is important to acknowledge the value of non-pharmacologic interventions, such as pulmonary rehabilitation and patient self-management education, which have proven to be invaluable tools for targeting the affective components of dyspnea. Furthermore, it is important to encourage maintenance of physical activity to optimize long-term patient outcomes. Here, we review the physiological and psychological consequences of activity-related dyspnea in COPD, assess the efficacy of modern management strategies in improving this common respiratory symptom, and discuss key unmet clinical and research needs that warrant further immediate attention.
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Affiliation(s)
- Nicola A Hanania
- Department of Medicine, Section of Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX, USA
| | - Denis E O'Donnell
- Division of Respirology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Abstract
Alongside imaging techniques, pulmonary function testing helps in the diagnosis of underlying disorders such as asthma and chronic obstructive pulmonary disease (COPD) or fibrosing lung disease. However, disease severity grading is also important, as well as disease follow-up under therapy. The value of spirometry as a first-line diagnostic test, whole-body plethysmography in advanced diagnostics, the measurement of transfer factor, as well as blood gas analysis are outlined. The importance of spiroergometry, echocardiography, and right-heart catheterization, particularly in the functional assessment of pulmonary vascular disorders, is described. Tests in respiratory sleep medicine, such as polysomnography, as well as tests for diagnosing chronic respiratory failure, are part of the respiratory physician's diagnostic armamentarium.
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Affiliation(s)
- M Held
- Innere Medizin, Klinikum Würzburg Mitte - Standort Missioklinik, Salvatorstr. 7, 97064, Würzburg, Deutschland.
| | - S Baron
- Innere Medizin, Klinikum Würzburg Mitte - Standort Missioklinik, Salvatorstr. 7, 97064, Würzburg, Deutschland
| | - B Jany
- Innere Medizin, Klinikum Würzburg Mitte - Standort Missioklinik, Salvatorstr. 7, 97064, Würzburg, Deutschland
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71
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Malerba M, Foci V, Patrucco F, Pochetti P, Nardin M, Pelaia C, Radaeli A. Single Inhaler LABA/LAMA for COPD. Front Pharmacol 2019; 10:390. [PMID: 31105560 PMCID: PMC6494943 DOI: 10.3389/fphar.2019.00390] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/29/2019] [Indexed: 01/04/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a common disabling disease characterized by progressive airflow obstruction. Great efforts were spent in the development of drugs able to improve symptoms, quality of life, reduce exacerbations, hospitalizations and the frequency of death of patients with COPD. The cornerstones of treatment are bronchodilator drugs of two different classes: beta agonists and muscarinic antagonists. Currently the Global initiative for COPD suggests the use of long acting beta agonists (LABAs) and long acting muscarinic antagonists (LAMAs) in combination for the majority of COPD patients, thus great interest is associated with the developing of LAMA/LABA fixed combination in the maintenance treatment of stable COPD. Many LAMA/LABA fixed dose combinations have been licensed in different countries and the clinical use of these drugs stimulated the performance of many clinical trials. The purpose of this review is a complete criticism of pharmacological and clinical aspects related to the use of LAMA/LABA single inhalers for the maintenance treatment of stable COPD, with particular mention to the most debated topics and future prospects in the field.
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Affiliation(s)
- Mario Malerba
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy.,Respiratory Unit, Sant'Andrea Hospital, Vercelli, Italy
| | - Valentina Foci
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy.,Respiratory Unit, Sant'Andrea Hospital, Vercelli, Italy
| | - Filippo Patrucco
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy.,Respiratory Unit, Sant'Andrea Hospital, Vercelli, Italy
| | - Patrizia Pochetti
- Respiratory Medicine, Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy.,Respiratory Unit, Sant'Andrea Hospital, Vercelli, Italy
| | - Matteo Nardin
- Department of Medicine, Spedali Civili di Brescia, Brescia, Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
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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] [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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Naya I, Tombs L, Lipson DA, Boucot I, Compton C. Impact of prior and concurrent medication on exacerbation risk with long-acting bronchodilators in chronic obstructive pulmonary disease: a post hoc analysis. Respir Res 2019; 20:60. [PMID: 30914064 PMCID: PMC6434823 DOI: 10.1186/s12931-019-1027-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/18/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Symptomatic patients with chronic obstructive pulmonary disease (COPD) and low exacerbation risk still have disease instability, which can be improved with better bronchodilation. We evaluated two long-acting bronchodilators individually and in combination on reducing exacerbation risk and the potential impact of concurrent medication in these patients. METHODS Integrated post hoc intent-to-treat (ITT) analysis of data from two large 24-week, randomized placebo (PBO)-controlled trials (NCT01313637, NCT01313650). Symptomatic patients with moderate-to-very-severe COPD with/without an exacerbation history were randomized (2:3:3:3) to once-daily: PBO, umeclidinium/vilanterol (UMEC/VI 62.5/25 μg [NCT01313650] or 125/25 μg [NCT01313637]), UMEC (62.5 [NCT01313650] or 125 μg [NCT01313637]) or VI (25 μg) via the ELLIPTA inhaler. Medication subgroups were segmented by treatment status at screening: a) maintenance-naïve or on maintenance medications, b) inhaled corticosteroid [ICS]-free or ICS-treated, c) low or high albuterol use based on median run-in use (< 3.6 or ≥ 3.6 puffs/day). Time to first moderate/severe exacerbation (Cox proportional hazard model) and change from baseline in trough forced expiratory volume in 1 s (FEV1; mixed model repeated measures) were analyzed. Safety was also assessed. RESULTS Of 3021 patients (ITT population; UMEC/VI: n = 816; UMEC: n = 825; VI: n = 825; PBO: n = 555), 36% had a recent exacerbation history, 33% were maintenance-naïve, 51% were ICS-free. Mean baseline albuterol use was 5.1 puffs/day. In the ITT population, UMEC/VI, UMEC, and VI reduced the risk of a first exacerbation versus PBO by 58, 44, and 39%, respectively (all p < 0.05). UMEC/VI provided significant risk reductions versus PBO in all subgroups. VI had no benefit versus PBO in maintenance-naïve, ICS-free, and low rescue use patients and was significantly less effective than UMEC/VI in these subgroups. UMEC had no significant benefit versus PBO in maintenance-naïve and ICS-free patients. All bronchodilators improved FEV1 versus PBO, and UMEC/VI significantly improved FEV1 versus both monotherapies across all populations studied (p < 0.05). All bronchodilators were similarly well tolerated. CONCLUSIONS Results suggest that UMEC/VI reduces exacerbation risk versus PBO more consistently across medication subgroups than UMEC or VI, particularly in patients with no/low concurrent medication use. Confirmed prospectively, these findings may support first-line use of dual bronchodilation therapy in symptomatic low-risk patients.
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Affiliation(s)
- Ian Naya
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS UK
| | - Lee Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - David A. Lipson
- Respiratory Research and Development, GSK, Collegeville, PA USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Isabelle Boucot
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS UK
| | - Chris Compton
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS UK
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Pharmacology, toxicology and clinical safety of glycopyrrolate. Toxicol Appl Pharmacol 2019; 370:154-169. [PMID: 30905688 DOI: 10.1016/j.taap.2019.03.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 02/03/2023]
Abstract
The clinical use of the anticholinergic glycopyrrolate dates back to the early 1960s when it was first approved in the U.S. Since then, oral and inhalation formulations have been developed as therapeutic agents inhibiting the muscarinic acetylcholine receptor in various indications including chronic obstructive pulmonary disease (COPD), excessive salivation, and peptic ulcers. More recently, topical formulations of glycopyrrolate (GPB, also known as glycopyrronium bromide) have gained interest as a treatment option for excessive sweating (hyperhidrosis). The U.S. Food and Drug Administration (FDA) approved the first topical glycopyrronium product for the treatment of hyperhidrosis in 2018. Glycopyrrolate, as a quaternary amine, shows minimal penetration of the blood brain barrier which limits CNS side effects. In addition, lack of phototoxicity, genotoxicity and carcinogenicity makes it suitable for chronic indications. The information on the nonclinical and clinical safety profile of glycopyrronium supporting various therapeutically approved uses has been obtained from published literature, our own data as well as summary documents issued by regulatory bodies. Collectively, these data support the conclusion that the benefits of glycopyrronium generally outweigh the risks in chronic use indications that require muscarinic receptor antagonism to provide therapeutic effects.
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Wallace AE, Kaila S, Bayer V, Shaikh A, Shinde MU, Willey VJ, Napier MB, Singer JR. Health Care Resource Utilization and Exacerbation Rates in Patients with COPD Stratified by Disease Severity in a Commercially Insured Population. J Manag Care Spec Pharm 2019; 25:205-217. [PMID: 30698096 PMCID: PMC10397829 DOI: 10.18553/jmcp.2019.25.2.205] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality and is associated with substantial economic burden. There is a lack of data regarding COPD outcomes and costs in a real-world setting, particularly by Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity. OBJECTIVES To (a) characterize a commercially insured U.S. population with COPD and (b) assess prevalence of exacerbations, health care resource utilization (HCRU), costs, and treatment patterns in a cohort of patients with confirmed COPD, overall and stratified by GOLD stage. METHODS This retrospective observational cohort study used administrative claims data from the HealthCore Integrated Research Database to identify patients with ≥ 1 inpatient, emergency room (ER), or office visit claim for COPD between January 1, 2012, and November 30, 2013, and continuous enrollment for 1 year before and 2 years after the first COPD diagnosis date. Patients with a spirometry claim within 12 months were eligible for medical record abstraction to confirm COPD diagnosis (forced expiratory volume in 1 second [FEV1]/forced vital capacity ratio < 0.7) and GOLD 1-4 classification (based on postbronchodilator FEV1 percent predicted). HCRU, costs, treatment patterns, and rate of moderate/severe exacerbation were identified from diagnosis up to 24 months. Outcomes were analyzed by univariate analysis stratified by GOLD classification. Multivariable analysis was conducted to assess associations between GOLD classification and outcomes of interest. RESULTS 53,484 patients newly diagnosed with COPD were identified who met initial inclusion criteria: 14,293 (27%) had a qualifying spirometry claim, and 1,505 had confirmed COPD (GOLD 1, 333 [22%]; GOLD 2, 823 [55%]; GOLD 3, 317 [21%]; GOLD 4, 32 [2%]). Patients with greater disease severity had higher rates of moderate/severe COPD exacerbations (GOLD 1 and 2, 40.4 and 48.9 per 100 person-years, respectively; GOLD 3 and 4, 83.6 and 89.1 per 100 person-years, respectively). All-cause and COPD-related inpatient admissions, COPD-related office visits, and COPD-related ER visits were more prevalent with more severe GOLD classification. Mean annual COPD-related medical costs increased with GOLD classification ($5,945 for GOLD 1 patients, $18,070 for GOLD 4). COPD maintenance medication was filled by 42%, 56%, 73%, and 75% of patients in GOLD 1-4 (57% overall), respectively; combination corticosteroid/long-acting beta2-agonist inhalers were the most commonly used medication, regardless of GOLD classification. Patients with more severe disease had greater adherence (range 44%-68% of days covered for GOLD 1-4) and persistence (range 107-209 days for GOLD 1-4). CONCLUSIONS Trends toward increases in exacerbations, HCRU, and costs were observed as airflow limitation worsened. Adherence and persistence with COPD maintenance therapy was suboptimal even with severe disease. DISCLOSURES This study was supported by Boehringer Ingelheim Pharmaceuticals (Ridgefield, CT), which was given the opportunity to review the manuscript for medical and scientific accuracy, as well as intellectual property considerations. Willey and Singer are employees of HealthCore (parent company Anthem), which received funding from Boehringer Ingelheim to complete this study. Wallace and Shinde were employed by HealthCore at the time of this study. Wallace and Singer report stock ownership in Anthem. Napier is an employee of Anthem. Kaila, Bayer, and Shaikh are employees of Boehringer Ingelheim Pharmaceuticsls. Portions of this research were presented at the following conferences: (a) A. Wallace, S. Kaila, V. Zubek, A. Shaikh, M. Shinde, V. Willey, M. Napier, and J. Singer, Healthcare resource utilization, costs, and exacerbation rates in patients with COPD stratified by GOLD airflow limitation classification in a US commercially insured population, presented at AMCP Nexus 2017; October 16-19, 2017; Dallas, TX; and (b) A.E. Wallace, V. Zubek, S. Kaila, A. Shaikh, M. Shinde, V. Willey, M.B. Napier, and J.R. Singer, Real-world treatment patterns among newly diagnosed COPD patients according to GOLD airflow limitation severity classification in a U.S. commercially insured/Medicare Advantage population, presented at CHEST 2017 Annual Meeting; October 28-November 1, 2017; Toronto, Ontario, Canada.
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Affiliation(s)
| | - Shuchita Kaila
- 2 Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | - Valentina Bayer
- 2 Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | - Asif Shaikh
- 2 Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
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Crim C, Watkins ML, Bateman ED, Feldman GJ, Schenkenberger I, Kerwin EM, Crawford C, Pudi K, Ho S, Baidoo C, Castro-Santamaria R. Randomized dose-finding study of batefenterol via dry powder inhaler in patients with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:615-629. [PMID: 30880951 PMCID: PMC6413745 DOI: 10.2147/copd.s190603] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Batefenterol is a novel bifunctional muscarinic antagonist β2-agonist in development for COPD. The primary objective of this randomized, double-blind, placebo-controlled, active comparator, Phase IIb study was to model the dose–response of batefenterol and select a dose for Phase III development. Patients and methods Patients aged ≥40 years with COPD and FEV1 ≥30% and ≤70% predicted normal were randomized equally to batefenterol 37.5, 75, 150, 300, or 600 µg, placebo, or umeclidinium/vilanterol (UMEC/VI) 62.5/25 µg once daily. The primary and secondary endpoints were weighted-mean FEV1 over 0–6 hours post-dose and trough FEV1, analyzed by Bayesian and maximum likelihood estimation Emax of dose–response modeling, respectively, on day 42. Results In the intent-to-treat population (N=323), all batefenterol doses demonstrated statistically and clinically significant improvements from baseline vs placebo in the primary and secondary endpoints (191.1–292.8 and 182.2–244.8 mL, respectively), with a relatively flat dose–response. In the subgroup reversible to salbutamol, there were greater differences between batefenterol doses. Lung function improvements with batefenterol ≥150 µg were comparable with those with UMEC/VI. Batefenterol was well tolerated and no new safety signals were observed. Conclusion Batefenterol 300 µg may represent the optimal dose for Phase III studies.
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Affiliation(s)
- Courtney Crim
- GSK, Research and Development, Research Triangle Park, NC, USA,
| | | | - Eric D Bateman
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Edward M Kerwin
- Clinical Trials Division, Crisor LLC, Clinical Research Institute, Medford OR, USA
| | | | - Krishna Pudi
- Upstate Pharmaceutical Research, Greenville, SC, USA
| | - Shuyen Ho
- PAREXEL International, Durham, NC, USA
| | - Charlotte Baidoo
- GSK, Clinical Statistics, Stockley Park, Uxbridge, Middlesex, UK
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Maqsood U, Ho TN, Palmer K, Eccles FJR, Munavvar M, Wang R, Crossingham I, Evans DJW. Once daily long-acting beta2-agonists and long-acting muscarinic antagonists in a combined inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2019; 3:CD012930. [PMID: 30839102 PMCID: PMC6402279 DOI: 10.1002/14651858.cd012930.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a respiratory condition causing accumulation of mucus in the airways, cough, and breathlessness; the disease is progressive and is the fourth most common cause of death worldwide. Current treatment strategies for COPD are multi-modal and aim to reduce morbidity and mortality and increase patients' quality of life by slowing disease progression and preventing exacerbations. Fixed-dose combinations (FDCs) of a long-acting beta2-agonist (LABA) plus a long-acting muscarinic antagonist (LAMA) delivered via a single inhaler are approved by regulatory authorities in the USA, Europe, and Japan for the treatment of COPD. Several LABA/LAMA FDCs are available and recent meta-analyses have clarified their utility versus their mono-components in COPD. Evaluation of the efficacy and safety of once-daily LABA/LAMA FDCs versus placebo will facilitate the comparison of different FDCs in future network meta-analyses. OBJECTIVES We assessed the evidence for once-daily LABA/LAMA combinations (delivered in a single inhaler) versus placebo on clinically meaningful outcomes in patients with stable COPD. SEARCH METHODS We identified trials from Cochrane Airways' Specialised Register (CASR) and also conducted a search of the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch). We searched CASR and trial registries from their inception to 3 December 2018; we imposed no restriction on language of publication. SELECTION CRITERIA We included parallel-group and cross-over randomised controlled trials (RCTs) comparing once-daily LABA/LAMA FDC versus placebo. We included studies reported as full-text, those published as abstract only, and unpublished data. We excluded very short-term trials with a duration of less than 3 weeks. We included adults (≥ 40 years old) with a diagnosis of stable COPD. We included studies that allowed participants to continue using their ICS during the trial as long as the ICS was not part of the randomised treatment. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results to determine included studies, extracted data on prespecified outcomes of interest, and assessed the risk of bias of included studies; we resolved disagreements by discussion with a third review author. Where possible, we used a random-effects model to meta-analyse extracted data. We rated all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system and presented results in 'Summary of findings' tables. MAIN RESULTS We identified and included 22 RCTs randomly assigning 8641 people with COPD to either once-daily LABA/LAMA FDC (6252 participants) or placebo (3819 participants); nine studies had a cross-over design. Studies had a duration of between three and 52 weeks (median 12 weeks). The mean age of participants across the included studies ranged from 59 to 65 years and in 21 of 22 studies, participants had GOLD stage II or III COPD. Concomitant inhaled corticosteroid (ICS) use was permitted in all of the included studies (where stated); across the included studies, between 28% to 58% of participants were using ICS at baseline. Six studies evaluated the once-daily combination of IND/GLY (110/50 μg), seven studies evaluated TIO/OLO (2.5/5 or 5/5 μg), eight studies evaluated UMEC/VI (62.5/5, 125/25 or 500/25 μg) and one study evaluated ACD/FOR (200/6, 200/12 or 200/18 μg); all LABA/LAMA combinations were compared with placebo.The risk of bias was generally considered to be low or unknown (insufficient detail provided), with only one study per domain considered to have a high risk of bias except for the domain 'other bias' which was determined to be at high risk of bias in four studies (in three studies, disease severity was greater at baseline in participants receiving LABA/LAMA compared with participants receiving placebo, which would be expected to shift the treatment effect in favour of placebo).Compared to the placebo, the pooled results for the primary outcomes for the once-daily LABA/LAMA arm were as follows: all-cause mortality, OR 1.88 (95% CI 0.81 to 4.36, low-certainty evidence); all-cause serious adverse events (SAEs), OR 1.06 (95% CI 0.88 to 1.28, high-certainty evidence); acute exacerbations of COPD (AECOPD), OR 0.53 (95% CI 0.36 to 0.78, moderate-certainty evidence); adjusted St George's Respiratory Questionnaire (SGRQ) score, MD -4.08 (95% CI -4.80 to -3.36, high-certainty evidence); proportion of SGRQ responders, OR 1.75 (95% CI 1.54 to 1.99). Compared with placebo, the pooled results for the secondary outcomes for the once-daily LABA/LAMA arm were as follows: adjusted trough forced expiratory volume in one second (FEV1), MD 0.20 L (95% CI 0.19 to 0.21, moderate-certainty evidence); adjusted peak FEV1, MD 0.31 L (95% CI 0.29 to 0.32, moderate-certainty evidence); and all-cause AEs, OR 0.95 (95% CI 0.86 to 1.04; high-certainty evidence). No studies reported data for the 6-minute walk test. The results were generally consistent across subgroups for different LABA/LAMA combinations and doses. AUTHORS' CONCLUSIONS Compared with placebo, once-daily LABA/LAMA (either IND/GLY, UMEC/VI or TIO/OLO) via a combination inhaler is associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild-to-moderate COPD; UMEC/VI appears to reduce the rate of exacerbations in this population. These conclusions are supported by moderate or high certainty evidence based on studies with an observation period of up to one year.
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Affiliation(s)
- Usman Maqsood
- Sandwell and West Birmingham Hospitals NHS TrustDepartment of Respiratory MedicineBirminghamUK
| | - Terence N Ho
- St. Joseph's HealthcareFirestone Institute for Respiratory HealthHamiltonOntarioCanada
- McMaster UniversityHamiltonOntarioCanada
| | - Karen Palmer
- Lancashire Care NHS Foundation TrustNIHR Lancashire CRFPrestonUK
| | | | - Mohammed Munavvar
- Lancashire Teaching Hospitals NHS Foundation TrustDepartment of Respiratory MedicinePrestonUK
| | - Ran Wang
- Lancashire Teaching Hospitals NHS Foundation TrustDepartment of Respiratory MedicinePrestonUK
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Rhee CK, Yoshisue H, Lad R. Fixed-Dose Combinations of Long-Acting Bronchodilators for the Management of COPD: Global and Asian Perspectives. Adv Ther 2019; 36:495-519. [PMID: 30742242 PMCID: PMC6824447 DOI: 10.1007/s12325-019-0893-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Indexed: 01/02/2023]
Abstract
Maintenance bronchodilator therapy with long-acting β-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) is the cornerstone treatment for patients with stable chronic obstructive pulmonary disease (COPD). Fixed-dose combinations (FDCs) of LABA/LAMA are recommended for the majority of symptomatic COPD patients by global guidelines; regional guidelines such as the Japanese and Korean guidelines also provide similar recommendations for the use of LABA/LAMA FDCs. This review comprehensively describes the latest clinical evidence from key studies on the efficacy and safety of four approved LABA/LAMA fixed-dose combinations: indacaterol/glycopyrronium, vilanterol/umeclidinium, formoterol/aclidinium, and olodaterol/tiotropium. Additionally, in this review we describe the rationale behind the use of LABA/LAMA FDC therapy, key findings from the preclinical and clinical trial evaluation of respective LABA and LAMA monocomponents, and the efficacy and safety of LABA/LAMA FDCs. Special emphasis is placed on the clinical evidence for the monocomponents and LABA/LAMA FDCs from the Asian population. This detailed overview of the efficacy and safety of LABA/LAMA FDCs in global and Asian COPD patients is envisaged to provide a better understanding of the benefits of these therapies and to inform healthcare providers and patients on their appropriate use.Funding: Novartis Pharma K.K.
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Affiliation(s)
- Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | - Rahul Lad
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
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Rogliani P, Calzetta L, Matera MG, di Daniele N, Girolami A, Cazzola M, Ora J. Inhaled therapies and cardiovascular risk in patients with chronic obstructive pulmonary disease. Expert Opin Pharmacother 2019; 20:737-750. [PMID: 30707637 DOI: 10.1080/14656566.2019.1570133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) therapy includes a multi-dimensional approach, taking into account both symptoms of the patient and the number of acute exacerbations of COPD (AECOPDs). There are three main pharmaceutical classes currently available including long-acting muscarinic antagonists (LAMA), long-acting β2-agonists (LABA) and inhaled corticosteroids (ICS). COPD is a major risk factor for most cardiovascular diseases, and cardiac comorbidities are very common in COPD patients. Both LAMA and LABA have a considerable impact on cardiac function by stimulating cardiac β2-adrenergic receptors or inhibiting the heart M2 muscarinic receptors. ICS alone or in combination has never been associated with a real cardiovascular risk. AREAS COVERED This review explores the data published on the safety of COPD therapy and the implications for current pharmacotherapy. EXPERT OPINION Several studies have confirmed the good safety profile of bronchodilators available both in monotherapy and in association with other bronchodilators of different classes or with ICS despite the device used. Cardiovascular events in clinical trials are generally low and balanced between groups. The actual cardiovascular risk of fixed-dose combinations (FDCs) in an unselected COPD population will need to be investigated through post-marketing surveillance studies and observational studies.
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Affiliation(s)
- Paola Rogliani
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy.,b Division of Respiratory Medicine , University Hospital "Tor Vergata" , Rome , Italy
| | - Luigino Calzetta
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Maria Gabriella Matera
- c Department of Experimental Medicine , University of Campania Luigi Vanvitelli , Naples , Italy
| | - Nicola di Daniele
- d Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Andrea Girolami
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Mario Cazzola
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Josuel Ora
- b Division of Respiratory Medicine , University Hospital "Tor Vergata" , Rome , Italy
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Dual bronchodilator therapy for chronic obstructive pulmonary disease: evidence for the efficacy and Safety of fixed dose combination treatments in the setting of recent guideline updates. Curr Opin Pulm Med 2019; 24:130-137. [PMID: 29206657 DOI: 10.1097/mcp.0000000000000450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW Recent updates to the GOLD guidelines emphasize the use of combination LABA and LAMA bronchodilators for patients with chronic obstructive pulmonary disease with persistent dyspnea despite monotherapy or frequent exacerbations despite LAMA monotherapy. There are several commercially available LABA/LAMA fixed dose combination inhalers, which are likely to become the principle therapy for many patients with COPD. RECENT FINDINGS In the last 4 years, there have been a number of large clinical trials evaluating the efficacy and safety of combined LAMA and LABA bronchodilators. LAMA/LABA fixed dose combination therapies have consistently demonstrated clinically significant improvements to airway obstruction, dyspnea, and quality of life whenever compared with placebo, and more modest improvements compared with bronchodilator monotherapies and combined bronchodilator/inhaled corticosteroid therapy. SUMMARY New guidelines emphasize combination bronchodilators as a mainstay of therapy for many patients with symptomatic COPD and there are several new combination bronchodilator therapies available to patients. It is important for physicians and patients to understand the range and degree of expected clinical effects and the safety profiles of these new medications.
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Kaplan A, Chapman KR, Anees SM, Mayers I, Rochdi D, Djandji M, Préfontaine D, McIvor A. Real-life effectiveness of indacaterol-glycopyrronium after switching from tiotropium or salmeterol/fluticasone therapy in patients with symptomatic COPD: the POWER study. Int J Chron Obstruct Pulmon Dis 2019; 14:249-260. [PMID: 30718952 PMCID: PMC6343749 DOI: 10.2147/copd.s185485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose In contrast to randomized controlled trials (RCTs), changes in maintenance pharmacotherapy in clinical practice occur without a washout period. The Prospective cohort study for the real-life effectiveness evaluation of glycOpyrronium With indacatERol combination in the management of COPD in Canada (POWER) study evaluated the real-life effectiveness of indacaterol/glycopyrronium (IND/GLY) following a direct switch from a long-acting muscarinic antagonist (LAMA, tiotropium) or long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) maintenance treatment (salmeterol/fluticasone [SFC]). Methods POWER was a single-cohort, prospective, multicenter, interventional study in which patients with moderate-to-severe COPD, who remained symptomatic on their current treatment of once-daily (od) tiotropium 18 µg or twice-daily (bid) SFC (any dose), were switched to treatment with open-label IND/GLY 110/50 µg od for 16 weeks. Effectiveness end points were change from baseline in trough FEV1, transition dyspnea index (TDI) total scores, and COPD assessment test (CAT) scores at 16 weeks. Results Trough FEV1 improved by 175 mL at Week 16 in patients who switched to IND/GLY. The change was 176 mL (95% CI: 135-217) when switched from tiotropium and 172 mL (95% CI: 85-258) when switched from SFC fixed-dose combination (FDC). At Week 16, significant improvements were observed in the mean TDI total scores (Δ=2.5) and CAT scores (Δ=-6.5) after the switch to IND/GLY treatment (both P<0.0001). Additionally, IND/GLY was well tolerated in patients with moderate-to-severe COPD, and no safety signal was observed. Conclusion In clinical practice settings, a direct switch from previous treatment with either tiotropium or SFC to IND/GLY was safe and provided superior clinically significant improvements in lung function and patient-related outcomes in patients with moderate-to-severe COPD. Clinical trial registration NCT02202616.
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Affiliation(s)
- Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, ON, Canada,
| | - Kenneth R Chapman
- Division of Respiratory Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Syed M Anees
- Schulich School of Medicine & Dentistry - Western University, University of Windsor, ON, Canada
| | - Irvin Mayers
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Driss Rochdi
- Novartis Pharmaceuticals Canada Inc., Montreal, QC, Canada
| | - Michel Djandji
- Novartis Pharmaceuticals Canada Inc., Montreal, QC, Canada
| | | | - Andrew McIvor
- Department of Medicine, McMaster University, Firestone Institute for Respiratory Health, Hamilton, ON, Canada
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Lehmann S, Ringbæk T, Løkke A, Grote L, Hedner J, Lindberg E. A randomized trial to determine the impact of indacaterol/glycopyrronium on nighttime oxygenation and symptoms in patients with moderate-to-severe COPD: the DuoSleep study. Int J Chron Obstruct Pulmon Dis 2019; 14:199-210. [PMID: 30666100 PMCID: PMC6330967 DOI: 10.2147/copd.s184127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE This study investigated the effect of dual bronchodilation with the long-acting β-receptor agonist/long-acting muscarinic antagonist combination, indacaterol/glycopyrronium (IND/GLY), on nighttime oxygenation, lung function, sleep quality, and symptoms in patients with moderate-to-severe COPD. PATIENTS AND METHODS This was a 4-week, double-blind, multicenter, placebo-controlled, two-period crossover study. Patients were randomized in a 1:1 ratio to receive IND/GLY 110/50 µg once daily or matching placebo. The primary objective was to evaluate the effect of treatment with IND/GLY on mean nighttime oxygenation, compared with placebo. The secondary objective was to determine the time spent <90% in blood oxygen saturation (SpO2) compared with placebo. Exploratory objectives were to assess the effect of IND/GLY, compared with placebo, on sleep quality measured by the Medical Outcomes Study (MOS) Sleep Scale and the COPD and Asthma Sleep Impact Scale (CASIS) questionnaires and on symptoms assessed by COPD Assessment Test (CAT) questionnaire. RESULTS In total, 38 patients were randomized (n=22, IND/GLY; n=16, placebo). The change in nighttime oxygenation (SpO2) was similar, and there was a comparable difference in time spent <90% SpO2 between IND/GLY and placebo. Increases from baseline for the difference between IND/GLY and placebo for trough FEV1, FVC, and inspiratory capacity (P<0.05) were seen, with a corresponding reduction in residual volume and functional residual capacity (P<0.05). IND/GLY treatment showed an improvement in scores for CAT (P=0.0208), CASIS, and the MOS Sleep Scale measures, Sleep Problems Index I, Sleep Problems Index II (P=0.0315), Sleep Adequacy, Sleep Disturbance Scale, Somnolence Scale, and Short of Breath Scale (P=0.0031). CONCLUSION In this study, IND/GLY 110/50 µg once daily improved symptoms, sleep quality, and lung function, but showed no effect on nighttime oxygenation in patients with moderate-to-severe COPD.
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Affiliation(s)
- Sverre Lehmann
- Department of Thoracic Medicine, Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway,
- Section of Thoracic Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway,
| | - Thomas Ringbæk
- Department of Pulmonary Medicine, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Anders Løkke
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Ludger Grote
- Sleep Disorders Center, Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Hedner
- Department of Internal Medicine, Center for Sleep and Wake Disorders, University of Gothenburg and Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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Martinez FJ, Abrahams RA, Ferguson GT, Bjermer L, Grönke L, Voß F, Singh D. Effects of baseline symptom burden on treatment response in COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:181-194. [PMID: 30655665 PMCID: PMC6324615 DOI: 10.2147/copd.s179912] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
RATIONALE In symptomatic patients with COPD, the decision whether to initiate maintenance treatment with a single agent or a combination of long-acting bronchodilators remains unclear. OBJECTIVE To investigate whether baseline symptomatic status influences response to tiotropium/olodaterol treatment. MATERIALS AND METHODS Post hoc analysis of the randomized OTEMTO® studies (NCT01964352; NCT02006732), in which patients with moderate-to-severe COPD received placebo, tiotropium 5 µg, tiotropium/olodaterol 2.5/5 µg, or tiotropium/olodaterol 5/5 µg once daily for 12 weeks via the Respimat® inhaler (Boehringer Ingelheim, Ingelheim am Rhein, Germany). Impact of baseline symptomatic status (modified Medical Research Council [mMRC] score) on response to treatment with tiotropium/olodaterol 5/5 µg, tiotropium 5 µg, or placebo at Week 12 was assessed by St George's Respiratory Questionnaire (SGRQ) total score and response rate, transition dyspnea index (TDI) focal score and response rate, and trough forced expiratory volume in 1 second response. RESULTS Tiotropium/olodaterol improved SGRQ total scores and response rates compared with placebo and tiotropium for patients with baseline mMRC scores 0-1 and ≥2. For tiotropium/olodaterol vs tiotropium, greater improvements were observed for patients with mMRC ≥2 (SGRQ score adjusted mean treatment difference -3.44 [95% CI: -5.43, -1.46]; P=0.0007; SGRQ response rate ORs 2.09 [95% CI: 1.41, 3.10]; P=0.0002). Dyspnea, measured by TDI score, was consistently improved with tiotropium/olodaterol vs placebo for patients with mMRC scores 0-1 and ≥2 (adjusted mean treatment difference 1.63 [95% CI: 1.06, 2.20]; P<0.0001 and 1.60 [95% CI: 1.09, 2.10]; P<0.0001, respectively). In patients with mMRC scores 0-1 and ≥2, tiotropium/olodaterol consistently improved TDI response rate and lung function vs placebo and tiotropium. CONCLUSIONS Patients with COPD with more severe baseline dyspnea appear to derive greater health status benefit with tiotropium/olodaterol compared with tiotropium alone.
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Affiliation(s)
- Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA,
| | - Roger A Abrahams
- Morgantown Pulmonary Clinical Research, Morgantown, WV, USA
- Department of Pulmonary & Critical Care, Mon Health Care, Morgantown, WV, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Lars Grönke
- Biotechnology, CSL Behring, Wiesbaden, Germany
| | - Florian Voß
- Biostatistics + Data Sciences Corp., Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
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Königsdorfer N, Jörres RA, Söhler S, Welte T, Behr J, Ficker JH, Bals R, Watz H, Lutter JI, Lucke T, Biertz F, Alter P, Vogelmeier CF, Kahnert K. Adherence To Respiratory And Nonrespiratory Medication In Patients With COPD: Results Of The German COSYCONET Cohort. Patient Prefer Adherence 2019; 13:1711-1721. [PMID: 31631986 PMCID: PMC6791408 DOI: 10.2147/ppa.s223438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adherence to COPD medication is often considered to be lower than in other chronic diseases. In view of the frequent comorbidities of COPD, the economic impact of nonadherence and the potential for adverse effects, a direct comparison between the adherence to respiratory and nonrespiratory medication in the same patients seems of particular interest. OBJECTIVES We aimed to investigate the intake of respiratory and nonrespiratory medication in the same patients with COPD and frequent comorbidities. METHOD Within the COPD cohort COSYCONET, we contacted 1042 patients, mailing them a list with all medication regarding all their diseases, asking for regular, irregular and non-intake. RESULTS Valid responses were obtained in 707 patients covering a wide spectrum of drugs. Intake of LABA, LAMA or ICS was regular in 91.9% of patients, even higher for cardiovascular and antidiabetes medication but lower for hyperlipidemia and depression/anxiety medication. Regular intake of respiratory medication did not depend on GOLD groups A-D or grades 1-4, was highest in patients with concomitant cardiovascular disorders and was lowest for concomitant asthma. It was slightly larger for LAMA and LABA administered via combined compared to single inhalers, and lower when similar compounds were prescribed twice. Most differences did not reach statistical significance owing to the overall high adherence. CONCLUSION Our results indicate a high adherence to respiratory medication in participants of a COPD cohort, especially in those with cardiovascular comorbidities. Compared to the lower adherence reported in the literature for COPD patients, our observations still suggest some room for improvement, possibly through disease management programs.
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Affiliation(s)
- Norbert Königsdorfer
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Center Munich (CPC-M), Ludwig-Maximilians-Universität München, Munich80336, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Center Munich (CPC-M), Ludwig-Maximilians-Universität München, Munich80336, Germany
| | - Sandra Söhler
- ASCONET Study Coordination Office, University of Marburg, Marburg35043, Germany
| | - Tobias Welte
- Department of Pneumology, Hannover Medical School, Hannover30625, Germany
| | - Jürgen Behr
- Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich80336, Germany
| | - Joachim H Ficker
- Department of Respiratory Medicine, Allergology and Sleep Medicine, General Hospital Nuernberg, Paracelsus Medical University, Nuernberg, Germany
| | - Robert Bals
- Department of Internal Medicine V, Pneumology, Allergology, Respiratory Intensive Care Medicine, Saarland University Hospital, Homburg66424, Germany
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North, Member of the German Center for Lung Research, Grosshansdorf22927, Germany
| | - Johanna I Lutter
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München GmbH – German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Munich85764, Germany
| | - Tanja Lucke
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Center Munich (CPC-M), Ludwig-Maximilians-Universität München, Munich80336, Germany
| | - Frank Biertz
- Institute for Biostatistics, Hannover Medical School, Hannover30625, Germany
| | - Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University Marburg, Marburg35043, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University Marburg, Marburg35043, Germany
| | - Kathrin Kahnert
- Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich80336, Germany
- Correspondence: Kathrin Kahnert Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Ziemssenstr. 1, Munich80336, GermanyTel +49 89 4400 2590 Email
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Siddiqui MK, Shukla P, Jenkins M, Ouwens M, Guranlioglu D, Darken P, Biswas M. Systematic review and network meta-analysis of the efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler in comparison with other long-acting muscarinic antagonist/long-acting β 2-agonist fixed-dose combinations in COPD. Ther Adv Respir Dis 2019; 13:1753466619894502. [PMID: 31868101 PMCID: PMC6928544 DOI: 10.1177/1753466619894502] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/18/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Dual bronchodilation with a long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) fixed-dose combination (FDC) is an established treatment strategy for chronic obstructive pulmonary disease (COPD). The relative efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI 18/9.6 μg) in patients with moderate-to-very severe COPD, compared with other licensed LAMA/LABA FDCs, was investigated using an integrated Bayesian network meta-analysis (NMA). METHODS A systematic literature review and subsequent screening process identified randomized controlled trials of ⩾10 weeks' duration that enrolled patients aged ⩾40 years with moderate-to-very severe COPD and included at least one LAMA/LABA FDC or open LAMA + LABA treatment arm. NMAs were conducted for outcomes including change from baseline in forced expiratory volume in 1 s (FEV1), St George's Respiratory Questionnaire (SGRQ), and transition dyspnea index (TDI) parameters, annualized rate of exacerbations, use of rescue medication, adverse events, and all-cause withdrawals. Meta-regression and sensitivity analyses accounted for heterogeneity across studies. RESULTS In total, 29 studies including 34,617 patients contributed to the NMA for efficacy or safety outcomes at week 24 or exacerbations. For all LAMA/LABA FDCs with data available, significantly greater improvements in FEV1 [trough, peak, and area under the curve (AUC)0-4], SGRQ total score and TDI focal score at week 24, and annualized rate of moderate-to-severe exacerbations, were observed versus placebo. Where indirect comparisons were possible, differences between GFF MDI and other LAMA/LABA FDCs were small relative to established margins of clinical relevance, and not statistically significant. The safety and tolerability profile of GFF MDI was consistent with other LAMA/LABA FDCs and placebo. The results of the meta-regression were generally similar to the base case. CONCLUSIONS GFF MDI demonstrated comparable efficacy and safety outcomes to other LAMA/LABA FDCs. Personalization of treatment choice within the class on the basis of other factors such as patient preference may be appropriate.
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Affiliation(s)
| | | | | | | | | | | | - Mousumi Biswas
- AstraZeneca 101 Orchard Ridge Dr, Gaithersburg, MD 20878, USA
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Harrison EM, Kim V. Long-acting maintenance pharmacotherapy in chronic obstructive pulmonary disease. RESPIRATORY MEDICINE: X 2019. [DOI: 10.1016/j.yrmex.2019.100009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Meeraus W, Wood R, Jakubanis R, Holbrook T, Bizouard G, Despres J, Silva CCD, Nachbaur G, Landis SH, Punekar Y, Aguilaniu B, Ismaila AS. COPD treatment pathways in France: a retrospective analysis of electronic medical record data from general practitioners. Int J Chron Obstruct Pulmon Dis 2018; 14:51-63. [PMID: 30587961 PMCID: PMC6305135 DOI: 10.2147/copd.s181224] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Increasing availability of therapeutic options for COPD may drive new treatment pathways. This study describes COPD treatment in France, focusing on identifying initial treatment modifications in patients with COPD who either initiated long-acting bronchodilator (LABD)-based therapy or escalated to triple therapy (long-acting muscarinic antagonist [LAMA] + long-acting β2-agonist [LABA] + inhaled corticosteroid [ICS]). Methods This retrospective analysis of patients with COPD in a large general practitioner database (IQVIA Longitudinal Patient Database) in France included two cohorts: Cohort 1 – new initiators of LABD-based therapy (LAMA, LABA, LAMA + LABA, LAMA + ICS, LABA + ICS or LAMA + LABA + ICS); Cohort 2 – patients escalating to triple therapy from mono- or dual-bronchodilator-based maintenance treatment. Both cohorts were indexed on the date of initiation/escalation (January 2008–December 2013), and the first treatment modification (at class level) within the 18-month post-index observational period was described. Five mutually exclusive outcomes were defined: continuous use (no modification), discontinuation (permanent [≥91 days with no restart] or temporary [≥91 days with subsequent restart]), switch, and augmentation (Cohort 1 only). Exploratory analysis of Cohort 1 explored potential drivers of treatment initiation. Results Overall, 5,065 patients initiated LABD-based therapy (Cohort 1), and 501 escalated to triple therapy (Cohort 2). In Cohort 1, 7.0% of patients were continuous users, 46.5% discontinued permanently, 28.5% discontinued temporarily, 2.8% augmented (added LAMA and/or LABA and/or ICS), and 15.2% switched therapy. In Cohort 2, 18.2% of patients were continuous users, 7.2% discontinued permanently, 27.9% discontinued temporarily, and 46.7% switched therapy. Exploratory analyses showed that time since COPD diagnosis was first recorded, pre-index exacerbation events, and concomitant medical conditions were potential drivers of initial maintenance treatment choices. Conclusion Discontinuation among new initiators of LABD-based therapy was high in France, whereas few switched or augmented treatment. In comparison, permanent discontinuation within 18 months was low in patients escalating to triple therapy.
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Affiliation(s)
| | - Robert Wood
- Adelphi Real World, Bollington, Cheshire, UK
| | | | | | | | | | | | | | | | | | | | - Afisi S Ismaila
- GlaxoSmithKline, Collegeville, PA, USA, .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada,
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André S, Conde B, Fragoso E, Boléo-Tomé JP, Areias V, Cardoso J. COPD and Cardiovascular Disease. Pulmonology 2018; 25:168-176. [PMID: 30527374 DOI: 10.1016/j.pulmoe.2018.09.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 09/20/2018] [Indexed: 01/19/2023] Open
Abstract
COPD is one of the major public health problems in people aged 40 years or above. It is currently the 4th leading cause of death in the world and projected to be the 3rd leading cause of death by 2020. COPD and cardiac comorbidities are frequently associated. They share common risk factors, pathophysiological processes, signs and symptoms, and act synergistically as negative prognostic factors. Cardiac disease includes a broad spectrum of entities with distinct pathophysiology, treatment and prognosis. From an epidemiological point of view, patients with COPD are particularly vulnerable to cardiac disease. Indeed, mortality due to cardiac disease in patients with moderate COPD is higher than mortality related to respiratory failure. Guidelines reinforce that the control of comorbidities in COPD has a clear benefit over the potential risk associated with the majority of the drugs utilized. On the other hand, the true survival benefits of aggressive treatment of cardiac disease and COPD in patients with both conditions have still not been clarified. Given their relevance in terms of prevalence and prognosis, we will focus in this paper on the management of COPD patients with ischemic coronary disease, heart failure and dysrhythmia.
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Affiliation(s)
- S André
- Pulmonology Department, Hospital Egas Moniz, Centro Hospitalar de Lisboa Ocidental, EPE (CHLO), Lisbon, Portugal
| | - B Conde
- Pulmonology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - E Fragoso
- Pulmonology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, EPE (CHLN), Lisbon, Portugal
| | - J P Boléo-Tomé
- Pulmonology Department, Hospital Prof. Doutor Fernando Fonseca, EPE, Amadora, Portugal
| | - V Areias
- Pulmonology Department, Hospital de Faro, Centro Hospitalar do Algarve, EPE, Faro, Portugal; Department of Biomedical Sciences and Medicine, Algarve University, Portugal
| | - J Cardoso
- Pulmonology Department, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, EPE (CHLC), Lisbon, Portugal; Nova Medical School, Nova University, Lisbon, Portugal.
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Oba Y, Keeney E, Ghatehorde N, Dias S. Dual combination therapy versus long-acting bronchodilators alone for chronic obstructive pulmonary disease (COPD): a systematic review and network meta-analysis. Cochrane Database Syst Rev 2018; 12:CD012620. [PMID: 30521694 PMCID: PMC6517098 DOI: 10.1002/14651858.cd012620.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Long-acting bronchodilators such as long-acting β-agonist (LABA), long-acting muscarinic antagonist (LAMA), and LABA/inhaled corticosteroid (ICS) combinations have been used in people with moderate to severe chronic obstructive pulmonary disease (COPD) to control symptoms such as dyspnoea and cough, and prevent exacerbations. A number of LABA/LAMA combinations are now available for clinical use in COPD. However, it is not clear which group of above mentioned inhalers is most effective or if any specific formulation works better than the others within the same group or class. OBJECTIVES To compare the efficacy and safety of available formulations from four different groups of inhalers (i.e. LABA/LAMA combination, LABA/ICS combination, LAMA and LABA) in people with moderate to severe COPD. The review will update previous systematic reviews on dual combination inhalers and long-acting bronchodilators to answer the questions described above using the strength of a network meta-analysis (NMA). SEARCH METHODS We identified studies from the Cochrane Airways Specialised Register, which contains several databases. We also conducted a search of ClinicalTrials.gov and manufacturers' websites. The most recent searches were conducted on 6 April 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs) that recruited people aged 35 years or older with a diagnosis of COPD and a baseline forced expiratory volume in one second (FEV1) of less than 80% of predicted. We included studies of at least 12 weeks' duration including at least two active comparators from one of the four inhaler groups. DATA COLLECTION AND ANALYSIS We conducted NMAs using a Bayesian Markov chain Monte Carlo method. We considered a study as high risk if recruited participants had at least one COPD exacerbation within the 12 months before study entry and as low risk otherwise. Primary outcomes were COPD exacerbations (moderate to severe and severe), and secondary outcomes included symptom and quality-of-life scores, safety outcomes, and lung function. We collected data only for active comparators and did not consider placebo was not considered. We assumed a class/group effect when a fixed-class model fitted well. Otherwise we used a random-class model to assess intraclass/group differences. We supplemented the NMAs with pairwise meta-analyses. MAIN RESULTS We included a total of 101,311 participants from 99 studies (26 studies with 32,265 participants in the high-risk population and 73 studies with 69,046 participants in the low-risk population) in our systematic review. The median duration of studies was 52 weeks in the high-risk population and 26 weeks in the low-risk population (range 12 to 156 for both populations). We considered the quality of included studies generally to be good.The NMAs suggested that the LABA/LAMA combination was the highest ranked treatment group to reduce COPD exacerbations followed by LAMA in the both populations.There is evidence that the LABA/LAMA combination decreases moderate to severe exacerbations compared to LABA/ICS combination, LAMA, and LABA in the high-risk population (network hazard ratios (HRs) 0.86 (95% credible interval (CrI) 0.76 to 0.99), 0.87 (95% CrI 0.78 to 0.99), and 0.70 (95% CrI 0.61 to 0.8) respectively), and that LAMA decreases moderate to severe exacerbations compared to LABA in the high- and low-risk populations (network HR 0.80 (95% CrI 0.71 to 0.88) and 0.87 (95% CrI 0.78 to 0.97), respectively). There is evidence that the LABA/LAMA combination reduces severe exacerbations compared to LABA/ICS combination and LABA in the high-risk population (network HR 0.78 (95% CrI 0.64 to 0.93) and 0.64 (95% CrI 0.51 to 0.81), respectively).There was a general trend towards a greater improvement in symptom and quality-of-life scores with the combination therapies compared to monotherapies, and the combination therapies were generally ranked higher than monotherapies.The LABA/ICS combination was the lowest ranked in pneumonia serious adverse events (SAEs) in both populations. There is evidence that the LABA/ICS combination increases the odds of pneumonia compared to LAMA/LABA combination, LAMA and LABA (network ORs: 1.69 (95% CrI 1.20 to 2.44), 1.78 (95% CrI 1.33 to 2.39), and 1.50 (95% CrI 1.17 to 1.92) in the high-risk population and network or pairwise OR: 2.33 (95% CI 1.03 to 5.26), 2.02 (95% CrI 1.16 to 3.72), and 1.93 (95% CrI 1.29 to 3.22) in the low-risk population respectively). There were significant overlaps in the rank statistics in the other safety outcomes including mortality, total, COPD, and cardiac SAEs, and dropouts due to adverse events.None of the differences in lung function met a minimal clinically important difference criterion except for LABA/LAMA combination versus LABA in the high-risk population (network mean difference 0.13 L (95% CrI 0.10 to 0.15). The results of pairwise meta-analyses generally agreed with those of the NMAs. There is no evidence to suggest intraclass/group differences except for lung function at 12 months in the high-risk population. AUTHORS' CONCLUSIONS The LABA/LAMA combination was the highest ranked treatment group to reduce COPD exacerbations although there was some uncertainty in the results. LAMA containing inhalers may have an advantage over those without a LAMA for preventing COPD exacerbations based on the rank statistics. Combination therapies appear more effective than monotherapies for improving symptom and quality-of-life scores. ICS-containing inhalers are associated with an increased risk of pneumonia.Our most comprehensive review including intraclass/group comparisons, free combination therapies, 99 studies, and 20 outcomes for each high- and low-risk population summarises the current literature and could help with updating existing COPD guidelines.
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Affiliation(s)
- Yuji Oba
- University of MissouriDivision of Pulmonary and Critical Care MedicineColumbiaMOUSA
| | - Edna Keeney
- University of BristolPopulation Health Sciences, Bristol Medical SchoolBristolUK
| | - Namratta Ghatehorde
- University of MissouriDivision of Pulmonary and Critical Care MedicineColumbiaMOUSA
| | - Sofia Dias
- University of YorkCentre for Reviews and DisseminationHeslingtonYorkUKYO10 5DD
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Reisner C, Miller J, DePetrillo P, Maes A, Siddiqui S, Martin UJ. Pharmacokinetics and safety of a single dose of the novel LAMA/LABA fixed-dose combination of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler, formulated using co-suspension delivery technology, in Japanese healthy subjects. Pulm Pharmacol Ther 2018; 53:33-38. [DOI: 10.1016/j.pupt.2018.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/23/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022]
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Alcázar Navarrete B, Boucot I, Naya I, Tombs L, Lipson DA, Compton C, Sousa AR, Feldman G. Umeclidinium/Vilanterol Versus Tiotropium/Olodaterol in Maintenance-Naïve Patients with Moderate Symptomatic Chronic Obstructive Pulmonary Disease: A Post Hoc Analysis. Pulm Ther 2018; 4:171-183. [PMID: 32026389 PMCID: PMC6967227 DOI: 10.1007/s41030-018-0057-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Appropriate timing for dual bronchodilator therapy initiation in chronic obstructive pulmonary disease (COPD) management is uncertain. Combination therapy is recommended as step-up from monotherapy or first-line treatment in patients with persistent symptoms. In this setting, umeclidinium/vilanterol (UMEC/VI) demonstrated improved lung function and reduced rescue medication use over tiotropium/olodaterol (TIO/OLO). This subgroup analysis explored efficacy differences between these combinations in patients naïve to COPD maintenance therapy before study entry. METHODS Post hoc analysis of an 8-week, randomized, open-label, assessor-blind, two-period crossover study (204990; NCT02799784) comparing UMEC/VI 62.5/25 mcg and TIO/OLO 5/5 mcg, focused on maintenance-naïve (MN) patients with moderate COPD and persistent symptoms (modified Medical Research Council dyspnea score ≥ 2). Change from baseline (CFB) in trough forced expiratory volume in 1 s (FEV1), percentage of FEV1 responders (CFB ≥ 100 ml), rescue medication use and safety were evaluated. RESULTS The MN population comprised 63% of the intent-to-treat (ITT) population (148/236 patients) and had similar baseline demographics. At week 8, adjusted mean (standard error) improvements in trough FEV1 from baseline were clinically meaningful for both combinations (UMEC/VI: 167 [17] ml; TIO/OLO 110 [18] ml; adjusted mean difference [95% confidence interval (CI)]: 57 [23-92] ml; p = 0.001; %CFB: 11 vs. 8%). Proportion of FEV1 responders was greater with UMEC/VI versus TIO/OLO at week 8 (60 vs. 42%; odds ratio [95% CI] 1.90 [1.12-3.22]; p = 0.018). Reduction in rescue medication use was 0.20 (95% CI 0.07-0.34) puffs/day greater with UMEC/VI versus TIO/OLO over weeks 1-8 (p = 0.003). Adverse events incidence was similar (UMEC/VI: 24%; TIO/OLO: 29%). CONCLUSIONS These results highlight that the efficacy difference between UMEC/VI and TIO/OLO demonstrated in the ITT population is maintained in MN patients. Greater lung function improvements with UMEC/VI versus TIO/OLO were accompanied by symptom improvements, as reflected in a significantly lower need for supplemental rescue medication. FUNDING GSK. TRIAL REGISTRATION NCT02799784.
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Affiliation(s)
| | | | - Ian Naya
- Global Respiratory Franchise, GSK, Brentford, Middlesex, UK
| | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - David A Lipson
- Respiratory Research and Development, GSK, Collegeville, PA, USA
| | - Chris Compton
- Global Respiratory Franchise, GSK, Brentford, Middlesex, UK
| | - Ana R Sousa
- Discovery Medicine, GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Gregory Feldman
- South Carolina Pharmaceutical Research, Spartanburg, SC, USA
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Cho EY, Kim SY, Kim MJ, Kim S, Park DA, Yoo KH, Park YB, Hwang YI, Rhee CK, Jung JY, Lee H, Park HY. Comparison of clinical efficacy between ultra-LABAs and ultra-LAMAs in COPD: a systemic review with meta-analysis of randomized controlled trials. J Thorac Dis 2018; 10:6522-6530. [PMID: 30746196 DOI: 10.21037/jtd.2018.11.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background A single long-acting bronchodilator, ultra-long acting muscarinic antagonist (ultra-LAMA) or ultra-long acting β2-agonist (ultra-LABA) is preferred for the initial treatment of patients with chronic obstructive pulmonary disease (COPD); however, there are few head-to-head comparative studies between the two. Here, a meta-analysis of randomized controlled trials was performed to compare the clinical efficacy between ultra-LABA and ultra-LAMA in patients with moderate-to-severe COPD. Methods MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched (to March 1, 2017) to identify all published randomized controlled trials. Results Of the 12,906 articles found by searching the databases, we obtained data from 10,591 patients with COPD (LABA, n=5,058; LAMA, n=5,533) in seven published studies. Our results showed that COPD exacerbation were significantly lower in patients taking ultra-LAMA than those taking ultra-LABA (odds ratio =0.857, P=0.0008). However, no significant differences were observed between ultra-LAMA and ultra-LABA patients regarding improvement in trough forced expiratory volume in 1 s, the transitional dyspnea index, or St. George's Respiratory Questionnaire score. Conclusions This study suggests that COPD exacerbation occurred less often in patients taking an ultra-LAMA than in those taking an ultra-LABA with similar efficacy of lung function and quality of life.
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Affiliation(s)
- Eun Yeong Cho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University of Medicine, Seoul, South Korea
| | - Se Yong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University of Medicine, Seoul, South Korea
| | - Min-Ji Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Seonwoo Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Dong Ah Park
- Division of Healthcare Technology Assessment Research, Office of Health Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, South Korea
| | - Kwang Ha Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, South Korea
| | - Yong Bum Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea.,Lung Research Institute of Hallym University College of Medicine, Chuncheon, South Korea
| | - Yong Il Hwang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyun Lee
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University of Medicine, Seoul, South Korea
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Aziz MIA, Tan LE, Wu DBC, Pearce F, Chua GSW, Lin L, Tan PT, Ng K. Comparative efficacy of inhaled medications (ICS/LABA, LAMA, LAMA/LABA and SAMA) for COPD: a systematic review and network meta-analysis. Int J Chron Obstruct Pulmon Dis 2018; 13:3203-3231. [PMID: 30349228 PMCID: PMC6186767 DOI: 10.2147/copd.s173472] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To assess the comparative efficacy of short-acting muscarinic antagonists (SAMAs), long-acting muscarinic antagonists (LAMAs), LAMA in combination with long-acting beta-agonists (LABAs; LAMA/LABAs) and inhaled corticosteroids (ICS) in combination with LABA (ICS/LABAs) for the maintenance treatment of COPD. MATERIALS AND METHODS We systematically reviewed 74 randomized controlled trials (74,832 participants) published up to 15 November 2017, which compared any of the interventions (SAMA [ipratropium], LAMA [aclidinium, glycopyrronium, tiotropium, umeclidinium], LAMA/LABA [aclidinium/formoterol, indacaterol/glycopyrronium, tiotropium/olodaterol, umeclidinium/vilanterol] and ICS/LABA [fluticasone/vilanterol, budesonide/formoterol, salmeterol/fluticasone]) with each other or with placebo. A random-effects network meta-analysis combining direct and indirect evidence was conducted to examine the change from baseline in trough FEV1, transition dyspnea index, St George's Respiratory Questionnaire and frequency of adverse events at weeks 12 and 24. RESULTS Inconsistency models were not statistically significant for all outcomes. LAMAs, LAMA/LABAs and ICS/LABAs led to a significantly greater improvement in trough FEV1 compared with placebo and SAMA monotherapy at weeks 12 and 24. All LAMA/LABAs, except aclidinium/formoterol, were statistically significantly better than LAMA monotherapy and ICS/LABAs in improving trough FEV1. Among the LAMAs, umeclidinium showed statistically significant improvement in trough FEV1 at week 12 compared to tiotropium and glycopyrronium, but the results were not clinically significant. LAMA/LABAs had the highest probabilities of being ranked the best agents in FEV1 improvement. Similar trends were observed for the transition dyspnea index and St George's Respiratory Questionnaire outcomes. There were no significant differences in the incidences of adverse events among all treatment options. CONCLUSION LAMA/LABA showed the greatest improvement in trough FEV1 at weeks 12 and 24 compared with the other inhaled drug classes, while SAMA showed the least improvement. There were no significant differences among the LAMAs and LAMA/LABAs within their respective classes.
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Affiliation(s)
| | - Ling Eng Tan
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | | | - Fiona Pearce
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | | | - Liang Lin
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | - Ping-Tee Tan
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | - Kwong Ng
- Agency for Care Effectiveness, Ministry of Health, Singapore,
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Rogliani P, Calzetta L, Braido F, Cazzola M, Clini E, Pelaia G, Rossi A, Scichilone N, Di Marco F. LABA/LAMA fixed-dose combinations in patients with COPD: a systematic review. Int J Chron Obstruct Pulmon Dis 2018; 13:3115-3130. [PMID: 30323582 PMCID: PMC6174911 DOI: 10.2147/copd.s170606] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the current evidence for long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combinations (FDCs) in the treatment of COPD. MATERIALS AND METHODS A systematic literature search of randomized controlled trials published in English up to September 2017 of LABA/LAMA FDCs vs LABA or LAMA or LABA/inhaled corticosteroid (ICS) FDCs in COPD patients was performed using PubMed, Embase, Scopus, and Google Scholar. Outcomes including forced expiratory volume in 1 second (FEV1), Transition Dyspnea Index (TDI) scores, St George's Respiratory Questionnaire (SGRQ) scores, exacerbations, exercise tolerance (endurance time [ET]), inspiratory capacity (IC), and rescue medication use were evaluated. RESULTS In total, 27 studies were included in the review. LABA/LAMA FDCs significantly improved lung function (FEV1) at 12 weeks compared with LABA or LAMA or LABA/ICS. These effects were maintained over time. Significant improvements with LABA/LAMA FDCs vs each evaluated comparator were also observed in TDI and SGRQ scores, even if significant differences between different LABA/LAMA FDCs were detected. Only the LABA/LAMA FDC indacaterol/glycopyrronium has shown superiority vs LAMA and LABA/ICS for reducing exacerbation rates, while olodaterol/tiotropium and indacaterol/glycopyrronium have been shown to improve ET and IC vs the active comparators. Rescue medication use was significantly reduced by LABA/LAMA FDCs vs the evaluated comparators. LABA/LAMA FDCs were safe, with no increase in the risk of adverse events with LABA/LAMA FDCs vs the monocomponents. CONCLUSION Evidence supporting the efficacy of LABA/LAMA FDCs for COPD is heterogeneous, particularly for TDI and SGRQ scores, exacerbation rates, ET, and IC. So far, indacaterol/glycopyrronium is the LABA/LAMA FDC that has the strongest evidence for superiority vs LABA, LAMA, and LABA/ICS FDCs across the evaluated outcomes. LABA/LAMA FDCs were safe; however, more data should be collected in a real-world setting to confirm their safety.
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Affiliation(s)
- Paola Rogliani
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy,
| | - Luigino Calzetta
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy,
| | - Fulvio Braido
- Department of Internal Medicine, IRCCS San Martino Genoa University Hospital, Genoa, Italy
| | - Mario Cazzola
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy,
| | - Enrico Clini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Girolamo Pelaia
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, Magna Græcia University, Catanzaro, Italy
| | - Andrea Rossi
- Pulmonary Unit, University of Verona, Verona, Italy
| | - Nicola Scichilone
- Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università degli Studi di Milano, Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
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95
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Population-based study of LAMA monotherapy effectiveness compared with LABA/LAMA as initial treatment for COPD in primary care. NPJ Prim Care Respir Med 2018; 28:36. [PMID: 30266978 PMCID: PMC6162319 DOI: 10.1038/s41533-018-0102-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 11/08/2022] Open
Abstract
This epidemiological study aimed to describe and compare the characteristics and outcomes of COPD patients starting treatment with a long-acting anti-muscarinic (LAMA) or a combination of a long-acting beta-2 agonist (LABA)/LAMA in primary care in Catalonia (Spain) over a one-year period. Data were obtained from the Information System for the Development in Research in Primary Care (SIDIAP), a population database containing information of 5.8 million inhabitants (80% of the population of Catalonia). Patients initiating treatment with a LAMA or LABA/LAMA in 2015 were identified, and information about demographic and clinical characteristics was collected. Then, patients were matched 1:1 for age, sex, FEV1%, history of exacerbations, history of asthma and duration of treatment, and the outcomes between the two groups were compared. During 2015, 5729 individuals with COPD started treatment with a LAMA (69.8%) or LAMA/LABA (30.2%). There were no remarkable differences between groups except for a lower FEV1 and more previous hospital admissions in individuals on LABA/LAMA. The number of tests and referrals was low and decreased in both groups during follow-up. For the same severity status, the evolution was similar with a reduction in exacerbations in both groups. Treatment was changed during follow-up in up to 34.2% of patients in the LABA/LAMA and 26.3% in the LAMA group, but adherence was equally good for both. Our results suggest that initial therapy with LAMA in monotherapy may be adequate in a significant group of mild to moderate patients with COPD and a low risk of exacerbations managed in primary care. A single rather than combined long-acting inhaler therapy may be adequate for most patients when treating mild to moderate chronic lung disease. Marc Miravitlles at the Hospital Universitari Vall d’Hebron, Barcelona, Spain, and co-workers have shown that, in the initial stages of chronic obstructive pulmonary disease (COPD), treatment with an inhaled drug called a long-acting anti-muscarinic agent (LAMA) is as effective as an alternative inhaler that combines LAMA with another drug (LABA). The researchers identified 5729 COPD patients from Catalonia starting on inhaled treatment in 2015 and followed up on their progress after 1 year. Patients starting on LAMA monotherapy were matched closely in terms of demographics and previous medical history to those starting on LAMA/LABA treatment. The team found no remarkable differences in clinical characteristics between the groups over the year.
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96
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Lipworth BJ, Collier DJ, Gon Y, Zhong N, Nishi K, Chen R, Arora S, Maes A, Siddiqui S, Reisner C, Martin UJ. Improved lung function and patient-reported outcomes with co-suspension delivery technology glycopyrrolate/formoterol fumarate metered dose inhaler in COPD: a randomized Phase III study conducted in Asia, Europe, and the USA. Int J Chron Obstruct Pulmon Dis 2018; 13:2969-2984. [PMID: 30310273 PMCID: PMC6167125 DOI: 10.2147/copd.s171835] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background COPD is a major global cause of mortality and morbidity. PINNACLE-4 evaluated the efficacy and safety of GFF MDI (glycopyrrolate/formoterol fumarate metered dose inhaler) in patients from Asia, Europe, and the USA with moderate-to-very severe COPD. Methods In this double-blind, placebo-controlled, Phase III study, patients were randomized to treatment with GFF MDI 18/9.6 μg, glycopyrrolate (GP) MDI 18 μg, formoterol fumarate (FF) MDI 9.6 μg, or placebo MDI (all twice daily) for 24 weeks. Lung function, patient-reported outcomes (symptoms and health-related quality of life), and safety were assessed. Results Of the 1,756 patients randomized, 1,740 patients were included in the intent-to-treat population (mean age 64.2 years, 74.1% male, and 40.2% Asian). GFF MDI significantly improved morning predose trough FEV1 at Week 24 (primary endpoint) vs placebo MDI, GP MDI, and FF MDI (least squares mean differences: 165, 59, and 72 mL, respectively; all P<0.0001). GFF MDI also significantly improved other lung function endpoints vs placebo MDI, GP MDI, and FF MDI and patient-reported outcomes vs placebo MDI and GP MDI. A larger proportion of patients treated with GFF MDI achieved the minimum clinically important difference in Transition Dyspnea Index score vs GP MDI and placebo MDI and in St George’s Respiratory Questionnaire score vs placebo MDI. Adverse event rates were similar across treatment groups. Conclusion These results demonstrated the efficacy of GFF MDI in patients with moderate-to-very severe COPD. GFF MDI was well tolerated, with a safety profile commensurate with long-acting bronchodilators.
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Affiliation(s)
- Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Dundee, Scotland, UK,
| | - David J Collier
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yasuhiro Gon
- Itabashi Hospital, Nihon University School of Medicine, Itabashi, Tokyo, Japan
| | - Nanshan Zhong
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Koichi Nishi
- Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Rongchang Chen
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | | | - Andrea Maes
- Pearl - a member of the AstraZeneca group, Morristown, NJ, USA
| | | | - Colin Reisner
- Pearl - a member of the AstraZeneca group, Morristown, NJ, USA.,AstraZeneca, Gaithersburg, MD, USA
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97
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D'Urzo AD, Cazzola M, Hanania NA, Buhl R, Maleki-Yazdi MR. New developments in optimizing bronchodilator treatment of COPD: a focus on glycopyrrolate/formoterol combination formulated by co-suspension delivery technology. Int J Chron Obstruct Pulmon Dis 2018; 13:2805-2819. [PMID: 30233171 PMCID: PMC6135066 DOI: 10.2147/copd.s113306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
COPD causes considerable health and economic burden worldwide, with incidence of the disease expected to continue to rise. Inhaled bronchodilators, such as long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs), are central to the maintenance treatment of patients with COPD. Clinical studies have demonstrated that combined LAMA + LABA therapies improve efficacy while retaining a safety profile similar to LAMA or LABA alone. This has led to the development of several LAMA/LABA fixed-dose combination (FDC) therapies, which provide patients with the convenience of two active compounds in a single inhaler. GFF MDI (Bevespi Aerosphere®) is an FDC of glycopyrrolate/formoterol fumarate 18/9.6 µg formulated using innovative co-suspension delivery technology for administration via metered dose inhaler (MDI). GFF MDI was developed to make a treatment option available for patients who have a requirement or preference to use an MDI, rather than a dry powder or soft mist inhaler. Now that several LAMA/LABA FDCs have been approved for use in COPD, we review the impact of dual-bronchodilator treatment on COPD therapy and discuss recent clinical studies that are helping to develop a more comprehensive understanding of how LAMA/LABA FDCs can improve patient outcomes.
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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,
| | - Mario Cazzola
- Department of Experimental Medicine and Surgery, Tor Vergata University of Rome, Rome, Italy
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | - M Reza Maleki-Yazdi
- Division of Respiratory Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada
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98
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Yawn BP, Make B. Treatment of Chronic Obstructive Pulmonary Disease in the Primary Care Setting: How Can We Achieve More for Our Patients? Am J Med 2018; 131:7-14. [PMID: 29778457 DOI: 10.1016/j.amjmed.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/13/2018] [Accepted: 05/04/2018] [Indexed: 01/07/2023]
Abstract
Chronic obstructive pulmonary disease is a debilitating and progressive disease that is both underdiagnosed and undertreated, affecting up to 1 in 10 older adults. Common symptoms, including dyspnea, productive cough, chest tightness, and fatigue, can reduce quality of life, the ability to participate in all types of activities, and overall health status in patients. Minimizing the impact of symptoms on patients' quality of life should be a key goal for physicians, and modest changes in current practice could make improvements in patients' lives. Here we review chronic obstructive pulmonary disease, its impact on patients, and how to improve symptom management.
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Affiliation(s)
- Barbara P Yawn
- Department of Family and Community Health, University of Minnesota, Minneapolis.
| | - Barry Make
- Division of Pulmonary and Critical Care Medicine, National Jewish Health, Denver, Colo
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99
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Skoupa J, Kasak V, Klimes J, Valena T. Indacaterol/Glycopyrronium versus Salmeterol/Fluticasone in Patients with COPD—A Cost-Effectiveness Analysis in the Czech Republic. Value Health Reg Issues 2018; 16:112-118. [DOI: 10.1016/j.vhri.2018.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 08/15/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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100
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Miravitlles M, Baek S, Vithlani V, Lad R. Optimal Bronchodilation for COPD Patients: Are All Long-Acting β₂-Agonist/Long-Acting Muscarinic Antagonists the Same? Tuberc Respir Dis (Seoul) 2018; 81:198-215. [PMID: 29926556 PMCID: PMC6030660 DOI: 10.4046/trd.2018.0040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 04/26/2018] [Accepted: 04/29/2018] [Indexed: 12/21/2022] Open
Abstract
Bronchodilators provide improvements in lung function and reductions in symptoms and exacerbations, and are the mainstay of pharmacological management of chronic obstructive pulmonary disease (COPD). The Global Initiative for Chronic Obstructive Lung Disease strategy recommends the use of a combination of long-acting β₂-agonist/long-acting muscarinic antagonists (LABA/LAMA) as the first-line treatment option in the majority of symptomatic patients with COPD. This review provides an indirect comparison of available LABA/LAMA fixed-dose combinations (FDCs) through discussion of important efficacy and safety data from the key literature, with the objective of providing physicians with a framework for informed decision-making. LABA/LAMA FDCs provided greater benefits compared with placebo and similar or greater benefits compared with tiotropium and salmeterol/fluticasone in improving lung function, dyspnea, health-related quality of life, reducing rescue medication use and preventing exacerbations, although with some variability in efficacy between individual FDCs; further, tolerability profiles were comparable among LABA/LAMA FDCs. However, there is a disparity in the amount of evidence generated for different LABA/LAMA FDCs. Thus, this review shows that all LABA/LAMA FDCs may not be the same and that care should be taken when extrapolating individual treatment outcomes to the entire drug class. It is important that physicians consider the efficacy gradient that exists among LABA/LAMA FDCs, and factors such as inhaler devices and potential biomarkers, when choosing the optimal bronchodilator treatment for long-term management of patients with COPD.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
| | | | | | - Rahul Lad
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
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