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Talman S, Uzun S, Djamin RS, Baart SJ, Grootenboers MJJH, Aerts J, van der Eerden M. Long-Term Azithromycin Maintenance Treatment in Patients with Frequent Exacerbations of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2021; 16:495-498. [PMID: 33688175 PMCID: PMC7935328 DOI: 10.2147/copd.s284397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/07/2021] [Indexed: 12/31/2022] Open
Abstract
Macrolides are effective in reducing the number of exacerbations in COPD patients with the frequent exacerbator phenotype. Our study did not show a persistent effect of azithromycin on exacerbation frequencies after more than one year of usage.
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Affiliation(s)
- Sander Talman
- Amphia Hospital Breda, Department of Pulmonary Medicine, Breda, 4800RK, the Netherlands
| | - Sevim Uzun
- Erasmus Medical Centre Rotterdam, Department of Pulmonary Medicine, Rotterdam, 3015 CE, the Netherlands
| | - Remco S Djamin
- Amphia Hospital Breda, Department of Pulmonary Medicine, Breda, 4800RK, the Netherlands
| | - Sara J Baart
- Erasmuc Medical Centre Rotterdam, Department of Biostatistics, Rotterdam, 3015 CE, the Netherlands
| | | | - Joachim Aerts
- Erasmus Medical Centre Rotterdam, Department of Pulmonary Medicine, Rotterdam, 3015 CE, the Netherlands
| | - Menno van der Eerden
- Erasmus Medical Centre Rotterdam, Department of Pulmonary Medicine, Rotterdam, 3015 CE, the Netherlands
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152
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Oliver ME, Hinks TSC. Azithromycin in viral infections. Rev Med Virol 2021; 31:e2163. [PMID: 32969125 PMCID: PMC7536932 DOI: 10.1002/rmv.2163] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/18/2022]
Abstract
Azithromycin (AZM) is a synthetic macrolide antibiotic effective against a broad range of bacterial and mycobacterial infections. Due to an additional range of anti-viral and anti-inflammatory properties, it has been given to patients with the coronaviruses SARS-CoV or MERS-CoV. It is now being investigated as a potential candidate treatment for SARS-CoV-2 having been identified as a candidate therapeutic for this virus by both in vitro and in silico drug screens. To date there are no randomised trial data on its use in any novel coronavirus infection, although a large number of trials are currently in progress. In this review, we summarise data from in vitro, murine and human clinical studies on the anti-viral and anti-inflammatory properties of macrolides, particularly AZM. AZM reduces in vitro replication of several classes of viruses including rhinovirus, influenza A, Zika virus, Ebola, enteroviruses and coronaviruses, via several mechanisms. AZM enhances expression of anti-viral pattern recognition receptors and induction of anti-viral type I and III interferon responses. Of relevance to severe coronavirus-19 disease (COVID-19), which is characterised by an over-exuberant innate inflammatory response, AZM also has anti-inflammatory properties including suppression of IL-1beta, IL-2, TNF and GM-CSF. AZM inhibits T cells by inhibiting calcineurin signalling, mammalian target of rapamycin activity and NFκB activation. AZM particularly targets granulocytes where it concentrates markedly in lysosomes, particularly affecting accumulation, adhesion, degranulation and apoptosis of neutrophils. Given its proven safety, affordability and global availability, tempered by significant concerns about antimicrobial stewardship, there is an urgent mandate to perform well-designed and conducted randomised clinical trials.
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Affiliation(s)
| | - Timothy S. C. Hinks
- Nuffield Department of Medicine Experimental Medicine, Respiratory Medicine Unit and National Institute for Health Research (NIHR), Oxford Biomedical Research Centre (BRC)University of OxfordOxfordUK
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153
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Venditto VJ, Haydar D, Abdel-Latif A, Gensel JC, Anstead MI, Pitts MG, Creameans J, Kopper TJ, Peng C, Feola DJ. Immunomodulatory Effects of Azithromycin Revisited: Potential Applications to COVID-19. Front Immunol 2021; 12:574425. [PMID: 33643308 PMCID: PMC7906979 DOI: 10.3389/fimmu.2021.574425] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/22/2021] [Indexed: 12/14/2022] Open
Abstract
The rapid advancement of the COVID-19 pandemic has prompted an accelerated pursuit to identify effective therapeutics. Stages of the disease course have been defined by viral burden, lung pathology, and progression through phases of the immune response. Immunological factors including inflammatory cell infiltration and cytokine storm have been associated with severe disease and death. Many immunomodulatory therapies for COVID-19 are currently being investigated, and preliminary results support the premise of targeting the immune response. However, because suppressing immune mechanisms could also impact the clearance of the virus in the early stages of infection, therapeutic success is likely to depend on timing with respect to the disease course. Azithromycin is an immunomodulatory drug that has been shown to have antiviral effects and potential benefit in patients with COVID-19. Multiple immunomodulatory effects have been defined for azithromycin which could provide efficacy during the late stages of the disease, including inhibition of pro-inflammatory cytokine production, inhibition of neutrophil influx, induction of regulatory functions of macrophages, and alterations in autophagy. Here we review the published evidence of these mechanisms along with the current clinical use of azithromycin as an immunomodulatory therapeutic. We then discuss the potential impact of azithromycin on the immune response to COVID-19, as well as caution against immunosuppressive and off-target effects including cardiotoxicity in these patients. While azithromycin has the potential to contribute efficacy, its impact on the COVID-19 immune response requires additional characterization so as to better define its role in individualized therapy.
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Affiliation(s)
- Vincent J. Venditto
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY, United States
| | - Dalia Haydar
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Ahmed Abdel-Latif
- Gill Heart Institute and Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - John C. Gensel
- Department of Physiology, Spinal Cord and Brain Injury Research Center, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Michael I. Anstead
- Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Michelle G. Pitts
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY, United States
| | - Jarrod Creameans
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, United States
| | - Timothy J. Kopper
- Department of Physiology, Spinal Cord and Brain Injury Research Center, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Chi Peng
- Gill Heart Institute and Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - David J. Feola
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, United States
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154
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Thomas D, McDonald VM, Simpson JL, Smith A, Gupta S, Majellano E, Gibson PG. Patterns of azithromycin use in obstructive airway diseases: a real-world observational study. Intern Med J 2021; 52:1016-1023. [PMID: 33527647 DOI: 10.1111/imj.15216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
Background and objective Low-dose long-term azithromycin is recommended in clinical practice guidelines for obstructive airway diseases (OADs), however, an optimal therapeutic regimen is not yet established. This study aimed to understand the patterns of azithromycin use in OADs, characterise the patients who received it, and evaluate its safety and efficacy using real-world data. METHODS We audited 91 patients who had received azithromycin for at least 4 weeks for the management of asthma, chronic obstructive pulmonary disease (COPD) or non-cystic fibrosis bronchiectasis. RESULTS The mean age was 65±18 years, 60% were female, and 48% were ex-smokers. The majority had asthma (75%) either alone (50%) or in combination with COPD (12%) or bronchiectasis (13%). Most (64%) reported cough or sputum at baseline. The most common treatment regimen was azithromycin 250mg daily (73%) for more than 1 year (57%), with only seven adverse events. There was a significant reduction in the proportions of patients requiring emergency department visits (48% versus 32%; p<0.001) and hospital admissions (35% versus 31%; p<0.001) after starting azithromycin. In 88% of cases, physicians favoured the use of azithromycin. CONCLUSION Physicians are currently using low-dose azithromycin for a long duration of more than one year for the management of OADs. The typical case-definition is an older non-smoking adult with persistent asthma, often in combination with another OAD, and presenting with bothersome cough or sputum. Azithromycin was well tolerated and led to reduced healthcare utilisation. Further research is required to establish an optimal dosage regimen of azithromycin in OADs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Dennis Thomas
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, Newcastle, NSW, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, Newcastle, NSW, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Jodie L Simpson
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, Newcastle, NSW, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Amber Smith
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, Newcastle, NSW, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Sachin Gupta
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, Newcastle, NSW, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Eleanor Majellano
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, Newcastle, NSW, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, Newcastle, NSW, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
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155
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Billatos E, Ash SY, Duan F, Xu K, Romanoff J, Marques H, Moses E, Han MK, Regan EA, Bowler RP, Mason SE, Doyle TJ, San José Estépar R, Rosas IO, Ross JC, Xiao X, Liu H, Liu G, Sukumar G, Wilkerson M, Dalgard C, Stevenson C, Whitney D, Aberle D, Spira A, San José Estépar R, Lenburg ME, Washko GR. Distinguishing Smoking-Related Lung Disease Phenotypes Via Imaging and Molecular Features. Chest 2021; 159:549-563. [PMID: 32946850 PMCID: PMC8039011 DOI: 10.1016/j.chest.2020.08.2115] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 08/11/2020] [Accepted: 08/15/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Chronic tobacco smoke exposure results in a broad range of lung pathologies including emphysema, airway disease and parenchymal fibrosis as well as a multitude of extra-pulmonary comorbidities. Prior work using CT imaging has identified several clinically relevant subgroups of smoking related lung disease, but these investigations have generally lacked organ specific molecular correlates. RESEARCH QUESTION Can CT imaging be used to identify clinical phenotypes of smoking related lung disease that have specific bronchial epithelial gene expression patterns to better understand disease pathogenesis? STUDY DESIGN AND METHODS Using K-means clustering, we clustered participants from the COPDGene study (n = 5,273) based on CT imaging characteristics and then evaluated their clinical phenotypes. These clusters were replicated in the Detection of Early Lung Cancer Among Military Personnel (DECAMP) cohort (n = 360), and were further characterized using bronchial epithelial gene expression. RESULTS Three clusters (preserved, interstitial predominant and emphysema predominant) were identified. Compared to the preserved cluster, the interstitial and emphysema clusters had worse lung function, exercise capacity and quality of life. In longitudinal follow-up, individuals from the emphysema group had greater declines in exercise capacity and lung function, more emphysema, more exacerbations, and higher mortality. Similarly, genes involved in inflammatory pathways (tumor necrosis factor-α, interferon-β) are more highly expressed in bronchial epithelial cells from individuals in the emphysema cluster, while genes associated with T-cell related biology are decreased in these samples. Samples from individuals in the interstitial cluster generally had intermediate levels of expression of these genes. INTERPRETATION Using quantitative CT imaging, we identified three groups of individuals in older ever-smokers that replicate in two cohorts. Airway gene expression differences between the three groups suggests increased levels of inflammation in the most severe clinical phenotype, possibly mediated by the tumor necrosis factor-α and interferon-β pathways. CLINICAL TRIAL REGISTRATION COPDGene (NCT00608764), DECAMP-1 (NCT01785342), DECAMP-2 (NCT02504697).
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Affiliation(s)
- Ehab Billatos
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Boston University, Boston, MA; Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA.
| | - Samuel Y Ash
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Fenghai Duan
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, RI
| | - Ke Xu
- Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA; Bioinformatics Program, Boston University College of Engineering, Boston, MA
| | - Justin Romanoff
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, RI
| | - Helga Marques
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, RI
| | - Elizabeth Moses
- Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA
| | - MeiLan K Han
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Elizabeth A Regan
- Department of Medicine, Division of Rheumatology, National Jewish Health, Denver, CO
| | - Russell P Bowler
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Stefanie E Mason
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Tracy J Doyle
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rubén San José Estépar
- Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Ivan O Rosas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - James C Ross
- Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Xiaohui Xiao
- Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA
| | - Hanqiao Liu
- Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA
| | - Gang Liu
- Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA
| | - Gauthaman Sukumar
- Department of Anatomy, Physiology & Genetics, The American Genome Center, Collaborative Health Initiative Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Matthew Wilkerson
- Department of Anatomy, Physiology & Genetics, The American Genome Center, Collaborative Health Initiative Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Clifton Dalgard
- Department of Anatomy, Physiology & Genetics, The American Genome Center, Collaborative Health Initiative Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Duncan Whitney
- Lung Cancer Initiative at Johnson & Johnson, New Brunswick, NJ
| | - Denise Aberle
- Department of Radiology, University of California at Los Angeles, Los Angeles, CA
| | - Avrum Spira
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Boston University, Boston, MA; Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA; Lung Cancer Initiative at Johnson & Johnson, New Brunswick, NJ
| | - Raúl San José Estépar
- Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Marc E Lenburg
- Department of Medicine, Section of Computational Biomedicine, Boston University, Boston, MA; Bioinformatics Program, Boston University College of Engineering, Boston, MA
| | - George R Washko
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
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156
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Abstract
Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder with significant morbidity and mortality. Despite its prevalence, COPD is underdiagnosed, and many patients do not receive a diagnosis until the disease is clinically advanced. Recent basic science and clinical research have focused on the early physiologic and pathobiologic changes in COPD with the hopes of improving diagnosis, providing targets for disease-modifying therapy, and identifying patients most likely to benefit from early intervention. Available treatments for COPD have grown substantially in the past 20 years with the introduction of new oral and inhaled medications as well as novel surgical and bronchoscopic procedures. This article summarizes some of the recent advances in our understanding of disease pathogenesis and treatment paradigms.
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Affiliation(s)
- Michael C Ferrera
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA; , ,
| | - Wassim W Labaki
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA; , ,
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA; , ,
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157
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Little C, Cosetti MK. A Narrative Review of Pharmacologic Treatments for COVID-19: Safety Considerations and Ototoxicity. Laryngoscope 2021; 131:1626-1632. [PMID: 33491234 PMCID: PMC8014300 DOI: 10.1002/lary.29424] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE/HYPOTHESIS The purpose of this review is to summarize evidence-based data regarding the ototoxic effects of potential COVID-19 therapeutics to treat patients suffering from SARS-CoV-2. METHODS Medications under investigation as novel therapeutics to treat COVID-19 were identified using the search term coronavirus therapeutics, COVID therapeutics, and SARS-CoV-2 therapeutics on ClinicalTrials.gov and the PubMed Database. A literature review was performed using the PubMed Database for each proposed COVID-19 therapeutic to identify relevant articles. Search criteria included Medical Subject Headings (MeSH) and key word search terms for ototoxicity, vestibulotoxicity, hearing disorders, and vertigo. RESULTS Six proposed COVID-19 therapeutics were identified as possessing ototoxic side effects including chloroquine and hydroxychloroquine, azithromycin, lopinavir-ritonavir, interferon, ribavirin, and ivermectin. CONCLUSIONS Available evidence suggests that ototoxic effects may be improved or mitigated by stopping the offending agent. Recognition of hearing loss, tinnitus, or imbalance/vertigo is therefore crucial to facilitate early intervention and prevent long-term damage. Hospitals should consider the inclusion of audiologic monitoring protocols for patients receiving COVID-19 therapeutics with known ototoxicity, especially in high-risk patient groups such as the elderly and hearing impaired. Laryngoscope, 131:1626-1632, 2021.
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Affiliation(s)
- Christine Little
- Department of Otolaryngology‐Head and Neck SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkU.S.A.
| | - Maura K. Cosetti
- Department of Otolaryngology‐Head and Neck SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkU.S.A.
- Ear InstituteNew York Eye and Ear Infirmary of Mount SinaiNew YorkNew YorkU.S.A.
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158
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High-Deductible Health Plans and Healthcare Access, Use, and Financial Strain in Those with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 17:49-56. [PMID: 31599647 DOI: 10.1513/annalsats.201905-400oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rationale: Medical treatment can improve quality of life and avert exacerbations for those with chronic obstructive pulmonary disease (COPD). High-deductible health plans (HDHPs) can increase exposure to medical costs, and might compromise healthcare access and financial well-being for patients with COPD.Objectives: To examine the association of HDHPs with healthcare access, utilization, and financial strain among individuals with COPD.Methods: We analyzed privately insured adults aged 40-64 years with COPD in the 2011-2017 National Health Interview Survey, which uses Internal Revenue Service-specified thresholds to classify health plans as "high" or "traditional" deductible coverage. We assessed the association between enrollment in an HDHP and indicators of cost-related impediments to care, financial strain, and healthcare utilization, adjusting for potential confounders.Results: Our sample included 803 individuals with an HDHP and 1,334 with a traditional plan. The two groups' demographic and health characteristics were similar. Individuals enrolled in an HDHP more frequently reported delayed or foregone care, cost-related medication nonadherence, medical bill problems, and financial strain. They also more frequently reported out-of-pocket healthcare spending in excess of $5,000 a year. Although the two groups' office visit rates were similar, those enrolled in an HDHP were more likely to report a hospitalization or emergency room visit in the past year.Conclusions: For patients with COPD, enrollment in an HDHP was associated with cost-related barriers to care, financial strain, and more frequent emergency room visits and hospitalizations.
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159
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Hinks TSC, Levine SJ, Brusselle GG. Treatment options in type-2 low asthma. Eur Respir J 2021; 57:13993003.00528-2020. [PMID: 32586877 DOI: 10.1183/13993003.00528-2020] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022]
Abstract
Monoclonal antibodies targeting IgE or the type-2 cytokines interleukin (IL)-4, IL-5 and IL-13 are proving highly effective in reducing exacerbations and symptoms in people with severe allergic and eosinophilic asthma, respectively. However, these therapies are not appropriate for 30-50% of patients in severe asthma clinics who present with non-allergic, non-eosinophilic, "type-2 low" asthma. These patients constitute an important and common clinical asthma phenotype, driven by distinct, yet poorly understood pathobiological mechanisms. In this review we describe the heterogeneity and clinical characteristics of type-2 low asthma and summarise current knowledge on the underlying pathobiological mechanisms, which includes neutrophilic airway inflammation often associated with smoking, obesity and occupational exposures and may be driven by persistent bacterial infections and by activation of a recently described IL-6 pathway. We review the evidence base underlying existing treatment options for specific treatable traits that can be identified and addressed. We focus particularly on severe asthma as opposed to difficult-to-treat asthma, on emerging data on the identification of airway bacterial infection, on the increasing evidence base for the use of long-term low-dose macrolides, a critical appraisal of bronchial thermoplasty, and evidence for the use of biologics in type-2 low disease. Finally, we review ongoing research into other pathways including tumour necrosis factor, IL-17, resolvins, apolipoproteins, type I interferons, IL-6 and mast cells. We suggest that type-2 low disease frequently presents opportunities for identification and treatment of tractable clinical problems; it is currently a rapidly evolving field with potential for the development of novel targeted therapeutics.
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Affiliation(s)
- Timothy S C Hinks
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Nuffield Dept of Medicine, Experimental Medicine, University of Oxford, Oxford, UK
| | - Stewart J Levine
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Guy G Brusselle
- Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.,Depts of Epidemiology and Respiratory Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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160
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Janjua S, Mathioudakis AG, Fortescue R, Walker RA, Sharif S, Threapleton CJ, Dias S. Prophylactic antibiotics for adults with chronic obstructive pulmonary disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 1:CD013198. [PMID: 33448349 PMCID: PMC8092479 DOI: 10.1002/14651858.cd013198.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by persistent respiratory symptoms and airflow limitation. Acute exacerbations punctuate the natural history of COPD and are associated with increased morbidity and mortality and disease progression. Chronic airflow limitation is caused by a combination of small airways (bronchitis) and parenchymal destruction (emphysema), which can impact day-to-day activities and overall quality of life. In carefully selected patients with COPD, long-term, prophylactic use of antibiotics may reduce bacterial load, inflammation of the airways, and the frequency of exacerbations. OBJECTIVES To assess effects of different prophylactic antibiotics on exacerbations, quality of life, and serious adverse events in people with COPD in three separate network meta-analyses (NMAs), and to provide rankings of identified antibiotics. SEARCH METHODS To identify eligible randomised controlled trials (RCTs), we searched the Cochrane Airways Group Specialised Register of trials and clinical trials registries. We conducted the most recent search on 22 January 2020. SELECTION CRITERIA We included RCTs with a parallel design of at least 12 weeks' duration evaluating long-term administration of antibiotics prophylactically compared with other antibiotics, or placebo, for patients with COPD. DATA COLLECTION AND ANALYSIS This Cochrane Review collected and updated pair-wise data from two previous Cochrane Reviews. Searches were updated and additional studies included. We conducted three separate network meta-analyses (NMAs) within a Bayesian framework to assess three outcomes: exacerbations, quality of life, and serious adverse events. For quality of life, we collected data from St George's Respiratory Questionnaire (SGRQ). Using previously validated methods, we selected the simplest model that could adequately fit the data for every analysis. We used threshold analysis to indicate which results were robust to potential biases, taking into account each study's contributions to the overall results and network structure. Probability ranking was performed for each antibiotic class for exacerbations, quality of life, and serious adverse events. MAIN RESULTS Characteristics of studies and participants Eight trials were conducted at multiple sites that included hospital clinics or academic health centres. Seven were single-centre trials conducted in hospital clinics. Two trials did not report settings. Trials durations ranged from 12 to 52 weeks. Most participants had moderate to severe disease. Mean age ranged from 64 years to 73 years, and more males were recruited (51% to 100%). Forced expiratory volume in one second (FEV₁) ranged from 0.935 to 1.36 L. Most participants had previous exacerbations. Data from 12 studies were included in the NMAs (3405 participants; 16 treatment arms including placebo). Prophylactic antibiotics evaluated were macrolides (azithromycin and erythromycin), tetracyclines (doxycyclines), quinolones (moxifloxacin) and macrolides plus tetracyclines (roxithromycin plus doxycycline). Risk of bias and threshold analysis Most studies were at low risk across domains, except detection bias, for which only seven studies were judged at low risk. In the threshold analysis for exacerbations, all comparisons in which one antibiotic was compared with another were robust to sampling variation, especially macrolide comparisons. Comparisons of classes with placebo were sensitive to potential bias, especially macrolide versus placebo, therefore, any bias in the comparison was likely to favour the active class, so any adjustment would bring the estimated relative effect closer to the null value, thus quinolone may become the best class to prevent exacerbations. Exacerbations Nine studies were included (2732 participants) in this NMA (exacerbations analysed as time to first exacerbation or people with one or more exacerbations). Macrolides and quinolones reduced exacerbations. Macrolides had a greater effect in reducing exacerbations compared with placebo (macrolides: hazard ratio (HR) 0.67, 95% credible interval (CrI) 0.60 to 0.75; quinolones: HR 0.89, 95% CrI 0.75 to 1.04), resulting in 127 fewer people per 1000 experiencing exacerbations on macrolides. The difference in exacerbations between tetracyclines and placebo was uncertain (HR 1.29, 95% CrI 0.66 to 2.41). Macrolides ranked first (95% CrI first to second), with quinolones ranked second (95% CrI second to third). Tetracyclines ranked fourth, which was lower than placebo (ranked third). Contributing studies were considered as low risk of bias in a threshold analysis. Quality of life (SGRQ) Seven studies were included (2237 participants) in this NMA. SGRQ scores improved with macrolide treatment compared with placebo (fixed effect-fixed class effect: mean difference (MD) -2.30, 95% CrI -3.61 to -0.99), but the mean difference did not reach the minimally clinical important difference (MCID) of 4 points. Tetracyclines and quinolones did not improve quality of life any more than placebo, and we did not detect a difference between antibiotic classes. Serious adverse events Nine studies were included (3180 participants) in the NMA. Macrolides reduced the odds of a serious adverse event compared with placebo (fixed effect-fixed class effect: odds ratio (OR) 0.76, 95% CrI 0.62 to 0.93). There was probably little to no difference in the effect of quinolone compared with placebo or tetracycline plus macrolide compared with placebo. There was probably little to no difference in serious adverse events between quinolones or tetracycline plus macrolide. With macrolide treatment 49 fewer people per 1000 experienced a serious adverse event compared with those given placebo. Macrolides ranked first, followed by quinolones. Tetracycline did not rank better than placebo. Drug resistance Ten studies reported drug resistance. Results were not combined due to variation in outcome measures. All studies concluded that prophylactic antibiotic administration was associated with the development of antimicrobial resistance. AUTHORS' CONCLUSIONS This NMA evaluated the safety and efficacy of different antibiotics used prophylactically for COPD patients. Compared to placebo, prolonged administration of macrolides (ranked first) appeared beneficial in prolonging the time to next exacerbation, improving quality of life, and reducing serious adverse events. No clear benefits were associated with use of quinolones or tetracyclines. In addition, antibiotic resistance was a concern and could not be thoroughly assessed in this review. Given the trade-off between effectiveness, safety, and risk of antibiotic resistance, prophylactic administration of antibiotics may be best reserved for selected patients, such as those experiencing frequent exacerbations. However, none of the eligible studies excluded patients with previously isolated non-tuberculous mycobacteria, which would contraindicate prophylactic administration of antibiotics, due to the risk of developing resistant non-tuberculous mycobacteria.
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Affiliation(s)
- Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University Foundation Trust, Manchester, UK
| | - Rebecca Fortescue
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Ruth Ae Walker
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sahar Sharif
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
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Dhar R, Talwar D, Singh V, Dumra H, Rajan S, Jindal SK. Expert recommendations on the role of macrolides in chronic respiratory diseases. Lung India 2021; 38:174-182. [PMID: 33687013 PMCID: PMC8098884 DOI: 10.4103/lungindia.lungindia_498_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: India contributes to 32% of the total global disability-adjusted life years, due to chronic respiratory diseases. This has led to a high rate of health loss from these diseases. Antibiotics are commonly used in the management of respiratory disorders. With excellent tissue penetration, prolonged tissue persistence, and favorable side effect profile, macrolides are one of the best treatment options being recommended for respiratory, urogenital, dermal, and other bacterial infections. Still, there is a lack of clinical trial data on the use of macrolides in the management of respiratory chronic disease, and hence, there is a need for clinical guidance on their use in Indian setting. Methods: A systematic review of the literature was conducted on PubMed, Cochrane database, and Google Scholar. Existing guidelines, meta-analyses, systematic reviews, randomized controlled trials (RCTs), non-RCTs, landmark studies, and key-cited articles were selected. Recommendations were based on available evidence and expert panel's logical empiricism and consensus. Results and Discussion: This article discusses evidence-based and clinical practice based management of chronic respiratory conditions including chronic obstructive pulmonary disease, asthma, bronchiectasis, diffusive panbronchiolitis, and organizing pneumonia. The authors reviewed different respiratory conditions, role of macrolides in their management, adverse events and antimicrobial resistance associated with macrolides, evidence review of various clinical trials, guideline recommendations, and clinical recommendations.
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Affiliation(s)
- Raja Dhar
- Department of Pulmonology, Fortis Hospital, Kolkata, West Bengal, India
| | - Deepak Talwar
- Respiratory Center, Pulmonology and Sleep Medicine, Metro Group of Hospitals, Noida, Uttar Pradesh, India
| | | | - Harjit Dumra
- "Sparsh" Chest Diseases Center, Ahmedabad, Gujarat, India
| | - Sujeet Rajan
- Respiratory Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - S K Jindal
- Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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162
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Guo N, He Q, Jin Y, Hou Z, Pan Y, Liu J, Sun C. Separation and characterization of impurity P in azithromycin product. J Pharm Biomed Anal 2020; 195:113853. [PMID: 33358623 DOI: 10.1016/j.jpba.2020.113853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Azithromycin is a macrolide antibiotic which is used to treat a wide variety of bacterial infections. Impurity P is one of the impurities in azithromycin product, which is registered in Pharmacopoeias of Europe and USA. However, to date, the structure of this impurity has still not been elucidated. In this work, we separated impurity P from azithromycin product using preparative chromatography and successfully identified its chemical structure using multiple analytical techniques. First, high-resolution ion trap-time-of-flight mass spectrometry (IT-TOF MS) was used to determine the accurate molecular mass ([M+H]+m/z 777.5121) and the chemical formula (C39H72N2O13) of the impurity. Second, Fourier transforming infrared spectroscopy (FT-IR), ultraviolet-visible absorption spectroscopy (UV-vis) and tandem mass spectrometry (MS/MS) analyses were performed to probe into the key functional groups of the impurity to aid the NMR analysis. Finally, the structure of the impurity was successfully resolved using multidimensional NMR. In addition, a mechanism for the formation of this impurity was proposed.
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Affiliation(s)
- Nian Guo
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, Zhejiang, 310058, China
| | - Quan He
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, Zhejiang, 310058, China
| | - Yong Jin
- Zhejiang Guobang Pharmaceutical Co. Ltd., Shangyu, Zhejiang, 312300, China
| | - Zhouke Hou
- Zhejiang Guobang Pharmaceutical Co. Ltd., Shangyu, Zhejiang, 312300, China
| | - Yuanjiang Pan
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, Zhejiang, 310058, China
| | - Jian Liu
- Department of Surgical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China.
| | - Cuirong Sun
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, Zhejiang, 310058, China.
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163
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Ferrand RA, McHugh G, Rehman AM, Mujuru H, Simms V, Majonga ED, Nicol MP, Flaegstad T, Gutteberg TJ, Gonzalez-Martinez C, Corbett EL, Rowland-Jones SL, Kranzer K, Weiss HA, Odland JO. Effect of Once-Weekly Azithromycin vs Placebo in Children With HIV-Associated Chronic Lung Disease: The BREATHE Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2028484. [PMID: 33331916 PMCID: PMC7747021 DOI: 10.1001/jamanetworkopen.2020.28484] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE HIV-associated chronic lung disease (HCLD) in children is associated with small airways disease, is common despite antiretroviral therapy (ART), and is associated with substantial morbidity. Azithromycin has antibiotic and immunomodulatory activity and may be effective in treating HCLD through reducing respiratory tract infections and inflammation. OBJECTIVE To determine whether prophylactic azithromycin is effective in preventing worsening of lung function and in reducing acute respiratory exacerbations (AREs) in children with HCLD taking ART. DESIGN, SETTING, AND PARTICIPANTS This double-blind, placebo-controlled, randomized clinical trial (BREATHE) was conducted between 2016 and 2019, including 12 months of follow-up, at outpatient HIV clinics in 2 public sector hospitals in Malawi and Zimbabwe. Participants were randomized 1:1 to intervention or placebo, and participants and study personnel were blinded to treatment allocation. Participants included children aged 6 to 19 years with perinatally acquired HIV and HCLD (defined as forced expiratory volume in 1 second [FEV1] z score < -1) who were taking ART for 6 months or longer. Data analysis was performed from September 2019 to April 2020. INTERVENTION Once-weekly oral azithromycin with weight-based dosing, for 48 weeks. MAIN OUTCOMES AND MEASURES All outcomes were prespecified. The primary outcome was the mean difference in FEV1 z score using intention-to-treat analysis for participants seen at end line. Secondary outcomes included AREs, all-cause hospitalizations, mortality, and weight-for-age z score. RESULTS A total of 347 individuals (median [interquartile range] age, 15.3 [12.7-17.7] years; 177 boys [51.0%]) were randomized, 174 to the azithromycin group and 173 to the placebo group; 162 participants in the azithromycin group and 146 placebo group participants had a primary outcome available and were analyzed. The mean difference in FEV1 z score was 0.06 (95% CI, -0.10 to 0.21; P = .48) higher in the azithromycin group than in the placebo group, a nonsignificant difference. The rate of AREs was 12.1 events per 100 person-years in the azithromycin group and 24.7 events per 100 person-years in the placebo groups (hazard ratio, 0.50; 95% CI, 0.27 to 0.93; P = .03). The hospitalization rate was 1.3 events per 100 person-years in the azithromycin group and 7.1 events per 100 person-years in the placebo groups, but the difference was not significant (hazard ratio, 0.24; 95% CI, 0.06 to 1.07; P = .06). Three deaths occurred, all in the placebo group. The mean weight-for-age z score was 0.03 (95% CI, -0.08 to 0.14; P = .56) higher in the azithromycin group than in the placebo group, although the difference was not significant. There were no drug-related severe adverse events. CONCLUSIONS AND RELEVANCE In this randomized clinical trial specifically addressing childhood HCLD, once-weekly azithromycin did not improve lung function or growth but was associated with reduced AREs; the number of hospitalizations was also lower in the azithromycin group but the difference was not significant. Future research should identify patient groups who would benefit most from this intervention and optimum treatment length, to maximize benefits while reducing the risk of antimicrobial resistance. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02426112.
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Affiliation(s)
- Rashida A. Ferrand
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Grace McHugh
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Andrea M. Rehman
- MRC International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Hilda Mujuru
- Department of Paediatrics, University of Zimbabwe, Harare, Zimbabwe
| | - Victoria Simms
- Biomedical Research and Training Institute, Harare, Zimbabwe
- MRC International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Mark P. Nicol
- Division of Clinical Microbiology, University of Cape Town, Cape Town, South Africa
- School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Trond Flaegstad
- Faculty of Health Sciences, UiT, The Arctic University of Norway, Tromsø, Norway
- Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Tore J. Gutteberg
- Faculty of Health Sciences, UiT, The Arctic University of Norway, Tromsø, Norway
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Carmen Gonzalez-Martinez
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Elizabeth L. Corbett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Katharina Kranzer
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Helen A. Weiss
- MRC International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jon O. Odland
- Faculty of Health Sciences, UiT, The Arctic University of Norway, Tromsø, Norway
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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164
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Al-Hasan MN, Al-Jaghbeer MJ. Use of Antibiotics in Chronic Obstructive Pulmonary Disease: What is Their Current Role in Older Patients? Drugs Aging 2020; 37:627-633. [PMID: 32691330 DOI: 10.1007/s40266-020-00786-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) has considerable morbidity and mortality in the older adult population. The role of antibiotics in the management of acute exacerbations of COPD (AECOPD) is currently evolving. Despite only mild benefits, most patients with AECOPD in ambulatory settings receive antibiotics based on clinical criteria. Utilization of point-of-care C-reactive protein (CRP) has reduced antibiotic prescriptions by 20% without compromising clinical outcomes. A strict protocol allowing antibiotic use only in patients with clinical criteria and CRP ≥ 20 mg/L has the potential to reduce antibiotic prescriptions for AECOPD in ambulatory settings by nearly 50%. Amoxicillin and doxycycline are commonly prescribed for AECOPD based on a favorable benefit-to-risk ratio. Prophylactic antibiotics have also been used in selected patients with severe COPD and frequent exacerbations. The use of continuous or intermittent azithromycin has demonstrated efficacy in reducing the frequency of AECOPD in this population; however, this approach has potential for the development of antibiotic resistance and adverse effects. The use of azithromycin prophylaxis in older patients with frequent AECOPD should be determined on a case-by-case basis after careful review, discussion, and counseling of the potential benefits and risks. The role of continuous doxycycline and pulsed moxifloxacin prophylaxis for frequent AECOPD remains controversial.
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Affiliation(s)
- Majdi N Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC, USA. .,Prisma Health University of South Carolina Medical Group, Columbia, SC, USA.
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165
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Hua JL, Hu WP, Zuo YH, Zhang J. Prevention of Acute Exacerbation in Subjects with Moderate-to-very Severe COPD by Modulating Lower Respiratory Microbiome: Protocol of a Prospective, Multicenter, Randomized Controlled Trial. Int J Chron Obstruct Pulmon Dis 2020; 15:2985-2990. [PMID: 33235447 PMCID: PMC7680162 DOI: 10.2147/copd.s274005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/26/2020] [Indexed: 11/23/2022] Open
Abstract
Background COPD is a global respiratory disease that has produced a worldwide health care burden. Acute exacerbation of COPD (AECOPD) is the leading cause of death in patients with COPD and accounts for the majority of expenditure of COPD management. The colonization of potential pathogenic bacteria in the lower respiratory tract is an important cause of the acute exacerbation especially in patients with moderate and severe COPD. Some clinical studies have shown the potential of oral probiotics, aerosol-inhaled amikacin and combined vaccination to prevent AECOPD. Methods and Analysis We hypothesize that patients with stable COPD will benefit from aerosol-inhaled amikacin, oral probiotics or combined vaccination in terms of preventing acute exacerbation of COPD, slowing the progression of the disease and improving their quality of life. The trial aimsto investigate the efficacy and safety of the above interventions to decolonize bacteria in the lower respiratory tract and prevent acute exacerbation of COPD. In the study, 144 patients with stable phase of moderate-to-very severe COPD will be recruited and randomized into aerosol-inhaled amikacin group, oral probiotics group, combined vaccination group and the control group at a 1:1:1:1 ratio. The primary outcome is time to the first COPD exacerbation. Other endpoints include colonization of potential pathogenic bacteria in induced sputum, microbiome in induced sputum, pulmonary function and symptoms of patients, inflammation level and adverse events, serious adverse events, and death.
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Affiliation(s)
- Jian-Lan Hua
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Wei-Ping Hu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yi-Hui Zuo
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
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166
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Ansari AW, Sharif-Askari FS, Jayakumar MN, Mohammed AK, Sharif-Askari NS, Venkatachalam T, Mahboub B, Schmidt RE, Hamoudi RA, Halwani R, Hamid Q. Azithromycin Differentially Alters TCR-Activated Helper T Cell Subset Phenotype and Effector Function. Front Immunol 2020; 11:556579. [PMID: 33117343 PMCID: PMC7575909 DOI: 10.3389/fimmu.2020.556579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/31/2020] [Indexed: 01/04/2023] Open
Abstract
In addition to their antibiotic activities, azithromycin (AZM) exhibits anti-inflammatory effects in various respiratory diseases. One of the potent anti-inflammatory mechanisms is through inhibition of CD4+ helper T (Th) cell effector function. However, their impact on specific Th subset is obscure. Herein, we demonstrate the cellular basis of phenotypic and functional alterations associated with Th subsets following AZM treatment in vitro. Using well-characterized Th subset specific chemokine receptors, we report significant suppression of T cell receptor (TCR)-stimulated hyperactivated CCR4+CXCR3+ (Th0) expansion compared to CCR4-CXCR3+ (Th1-like) and CCR4+CXCR3- (Th2-like) cells. Interestingly, this effect was associated with diminished cell proliferation. Furthermore, AZM significantly inhibited the inflammatory cytokines IFN-γ and IL-4 production, CCR4 and CXCR3 receptor expression, and viability of Th0, Th1-like, and Th2-like subsets. Our findings suggest that AZM differentially affects TCR-activated Th subsets phenotype and function, and CCR4 and CXCR3 downregulation and suppressed Th0 subset expansion could potentially influence their trafficking and differentiation into cytokine-producing effector cells.
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Affiliation(s)
- Abdul Wahid Ansari
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | | | | | - Abdul Khader Mohammed
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | | | - Thenmozhi Venkatachalam
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Bassam Mahboub
- Department of Pulmonary Medicine, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Reinhold E Schmidt
- Department of Clinical Immunology and Rheumatology, Hannover Medical School, Hanover, Germany
| | - Rifat Akram Hamoudi
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates.,Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Rabih Halwani
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Prince Abdullah Ben Khaled Celiac Disease Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Qutayba Hamid
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Meakins-Christie Laboratories, Faculty of Medicine, McGill University, Montreal, QC, Canada
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167
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Abstract
Inhaled therapy remains the cornerstone of chronic obstructive pulmonary disease pharmacologic care, but some systemic treatments can be of help when the burden of the disease remains high. Azithromycin, phosphodiesterase-4 inhibitors, and mucoactive agents can be used in such situations. The major difficulty remains in the identification of the optimal target populations. Another difficulty is to determine how these treatments should be positioned in the global treatment algorithm. For instance, should they be prescribed in addition to other antiinflammatory agents or should they replace them in some cases? Research is ongoing to identify new therapeutic targets.
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Affiliation(s)
- Nicolas Roche
- Respiratory Medicine, Pneumologie et Soins Intensifs Respiratoires, APHP Centre, Cochin Hospital, Université de Paris (Descartes), Institut Cochin (UMR 1016), 27, rue du Fbg St Jacques, Paris 75014, France.
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168
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Azithromycin Partially Mitigates Dysregulated Repair of Lung Allograft Small Airway Epithelium. Transplantation 2020; 104:1166-1176. [PMID: 31985728 DOI: 10.1097/tp.0000000000003134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Dysregulated airway epithelial repair following injury is a proposed mechanism driving posttransplant bronchiolitis obliterans (BO), and its clinical correlate bronchiolitis obliterans syndrome (BOS). This study compared gene and cellular characteristics of injury and repair in large (LAEC) and small (SAEC) airway epithelial cells of transplant patients. METHODS Subjects were recruited at the time of routine bronchoscopy posttransplantation and included patients with and without BOS. Airway epithelial cells were obtained from bronchial and bronchiolar brushing performed under radiological guidance from these patients. In addition, bronchial brushings were also obtained from healthy control subjects comprising of adolescents admitted for elective surgery for nonrespiratory-related conditions. Primary cultures were established, monolayers wounded, and repair assessed (±) azithromycin (1 µg/mL). In addition, proliferative capacity as well as markers of injury and dysregulated repair were also assessed. RESULTS SAEC had a significantly dysregulated repair process postinjury, despite having a higher proliferative capacity than large airway epithelial cells. Addition of azithromycin significantly induced repair in these cells; however, full restitution was not achieved. Expression of several genes associated with epithelial barrier repair (matrix metalloproteinase 7, matrix metalloproteinase 3, the integrins β6 and β8, and β-catenin) were significantly different in epithelial cells obtained from patients with BOS compared to transplant patients without BOS and controls, suggesting an intrinsic defect. CONCLUSIONS Chronic airway injury and dysregulated repair programs are evident in airway epithelium obtained from patients with BOS, particularly with SAEC. We also show that azithromycin partially mitigates this pathology.
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169
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Consensus document on the diagnosis and treatment of chronic bronchial infection in chronic obstructive pulmonary disease. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.arbr.2020.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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170
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Adibi A, Sin DD, Safari A, Johnson KM, Aaron SD, FitzGerald JM, Sadatsafavi M. The Acute COPD Exacerbation Prediction Tool (ACCEPT): a modelling study. THE LANCET. RESPIRATORY MEDICINE 2020; 8:1013-1021. [PMID: 32178776 DOI: 10.1016/s2213-2600(19)30397-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Accurate prediction of exacerbation risk enables personalised care for patients with chronic obstructive pulmonary disease (COPD). We developed and validated a generalisable model to predict individualised rate and severity of COPD exacerbations. METHODS In this risk modelling study, we pooled data from three COPD trials on patients with a history of exacerbations. We developed a mixed-effect model to predict exacerbations over 1 year. Severe exacerbations were those requiring inpatient care. Predictors were history of exacerbations, age, sex, body-mass index, smoking status, domiciliary oxygen therapy, lung function, symptom burden, and current medication use. Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE), a multicentre cohort study, was used for external validation. RESULTS The development dataset included 2380 patients, 1373 (58%) of whom were men. Mean age was 64·7 years (SD 8·8). Mean exacerbation rate was 1·42 events per year and 0·29 events per year were severe. When validated against all patients with COPD in ECLIPSE (mean exacerbation rate was 1·20 events per year, 0·27 events per year were severe), the area-under-curve (AUC) was 0·81 (95% CI 0·79-0·83) for at least two exacerbations and 0·77 (95% CI 0·74-0·80) for at least one severe exacerbation. Predicted exacerbation and observed exacerbation rates were similar (1·31 events per year for all exacerbations and 0·25 events per year for severe exacerbations vs 1·20 events per year and 0·27 events per year). In ECLIPSE, in patients with previous exacerbation history (mean exacerbation rate was 1·82 events per year, 0·40 events per year were severe), AUC was 0·73 (95% CI 0·70-0·76) for two or more exacerbations and 0·74 (95% CI 0·70-0·78) for at least one severe exacerbation. Calibration was accurate for severe exacerbations (predicted 0·37 events per year vs observed 0·40 events per year) and all exacerbations (predicted 1·80 events per year vs observed 1·82 events per year). INTERPRETATION This model can be used as a decision tool to personalise COPD treatment and prevent exacerbations. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Amin Adibi
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Don D Sin
- Division of Respiratory Medicine, Department of Medicine, The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Abdollah Safari
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Kate M Johnson
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada; Institute for Heart and Lung Health, Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada
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de la Rosa Carrillo D, López-Campos JL, Alcázar Navarrete B, Calle Rubio M, Cantón Moreno R, García-Rivero JL, Máiz Carro L, Olveira Fuster C, Martínez-García MÁ. Consensus Document on the Diagnosis and Treatment of Chronic Bronchial Infection in Chronic Obstructive Pulmonary Disease. Arch Bronconeumol 2020; 56:651-664. [PMID: 32540279 DOI: 10.1016/j.arbres.2020.04.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/22/2020] [Accepted: 04/01/2020] [Indexed: 02/07/2023]
Abstract
Although the chronic presence of microorganisms in the airways of patients with stable chronic obstructive pulmonary disease (COPD) confers a poor outcome, no recommendations have been established in disease management guidelines on how to diagnose and treat these cases. In order to guide professionals, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has prepared a document which aims to answer questions on the clinical management of COPD patients in whom microorganisms are occasionally or habitually isolated. Since the available scientific evidence is too heterogeneous to use in the creation of a clinical practice guideline, we have drawn up a document based on existing scientific literature and clinical experience, addressing the definition of different clinical situations and their diagnosis and management. The text was drawn up by consensus and approved by a large group of respiratory medicine experts with extensive clinical and scientific experience in the field, and has been endorsed by the SEPAR Scientific Committee.
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Affiliation(s)
| | - José Luís López-Campos
- Servicio de Neumología, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - Bernardino Alcázar Navarrete
- Servicio de Neumología, Hospital Regional Universitario de Málaga. Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, Málaga, España
| | - Myriam Calle Rubio
- Servicio de Neumología, Hospital de Alta Resolución de Loja, Loja, Granada, España
| | - Rafael Cantón Moreno
- Servicio de Neumología, Unidad de Infección Bronquial Crónica, Fibrosis Quística y Bronquiectasias, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Luis García-Rivero
- Servicio de Neumología, Hospital Clínico San Carlos. Departamento de Medicina, Facultad de Medicina, UCM, Madrid, España
| | - Luís Máiz Carro
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal. Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, España
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172
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Axson EL, Lewis A, Potts J, Pang M, Dickinson S, Vioix H, Quint JK. Inhaled therapies for chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMJ Open 2020; 10:e036455. [PMID: 32994234 PMCID: PMC7526304 DOI: 10.1136/bmjopen-2019-036455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 08/25/2020] [Accepted: 09/02/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To integrate evidence from randomised controlled trials (RCTs) and observational studies on the efficacy of inhaled treatments for chronic obstructive pulmonary disease using network meta-analyses. METHODS Systematic searches MEDLINE and Embase based on predetermined criteria. Network meta-analyses of RCTs investigated efficacy on exacerbations (long-term: ≥20 weeks of treatment; short-term: <20 weeks), lung function (≥12 weeks), health-related quality of life, mortality and adverse events. Qualitative comparisons of efficacies between RCTs and observational studies. RESULTS 212 RCTs and 19 observational studies were included. Compared with combined long-acting beta-adrenoceptor agonists and long-acting muscarinic antagonists (LABA+LAMA), triple therapy (LABA+LAMA+inhaled corticosteroid) was significantly more effective at reducing exacerbations (long-term 0.85 (95% CI: 0.78 to 0.94; short-term 0.67 (95% CI: 0.49 to 0.92)) and mortality (0.72 (95% CI: 0.59 to 0.89)) but was also associated with increased pneumonia (1.35 (95% CI: 1.10 to 1.67)). No differences in lung function (0.02 (95% CI: -0.10 to 0.14)), health-related quality of life (-1.12 (95% CI: -3.83 to 1.59)) or other adverse events (1.02 (95% CI: 0.96 to 1.08)) were found. Most of the observational evidence trended in the same direction as pooled RCT data. CONCLUSION Further evidence, especially pragmatic trials, are needed to fully understand the characteristics of patient subgroups who may benefit from triple therapy and for those whom the extra risk of adverse events, such as pneumonia, may outweigh any benefits. PROSPERO REGISTRATION NUMBER CRD42018088013.
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Affiliation(s)
- Eleanor L Axson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Adam Lewis
- National Heart and Lung Institute, Imperial College London, London, UK
| | - James Potts
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | | | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
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173
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van Dijk M, Gan CT, Koster TD, Wijkstra PJ, Slebos DJ, Kerstjens HAM, van der Vaart H, Duiverman ML. Treatment of severe stable COPD: the multidimensional approach of treatable traits. ERJ Open Res 2020; 6:00322-2019. [PMID: 32984420 PMCID: PMC7502698 DOI: 10.1183/23120541.00322-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/26/2020] [Indexed: 01/02/2023] Open
Abstract
Now that additional treatment options for severe chronic obstructive pulmonary disease (COPD) have emerged in recent years, patients with severe COPD should not be left in the rather hopeless situation of “there is nothing to improve” any more. Inertia or fatalism is a disservice to our patients. Ranging from advanced care planning to quite intense and demanding therapies such as multidisciplinary pulmonary rehabilitation, (endoscopic) lung volume reduction, chronic noninvasive ventilation and lung transplantation, caregivers should try to provide a personalised treatment for every severe COPD patient. In this review, we aim to describe the multidimensional approach to these patients at our centre along the lines of treatable traits leading to specific additional treatment modalities on top of standard care. Severe COPD is not hopeless; in light of treatment options such as pulmonary rehabilitation, bronchoscopic lung volume reduction, chronic noninvasive ventilation and lung transplantation, every patient deserves a personalised assessment of treatable traitshttps://bit.ly/2TO7jxB
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Affiliation(s)
- Marlies van Dijk
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Christiaan T Gan
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - T David Koster
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Peter J Wijkstra
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Hester van der Vaart
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands.,Centre of Rehabilitation Beatrixoord, Haren, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marieke L Duiverman
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
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174
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Li D, Duan Q, Weinkauf J, Kapasi A, Varughese R, Hirji A, Lien D, Meyer S, Laing B, Nagendran J, Halloran K. Azithromycin prophylaxis after lung transplantation is associated with improved overall survival. J Heart Lung Transplant 2020; 39:1426-1434. [PMID: 33041181 DOI: 10.1016/j.healun.2020.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/25/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Azithromycin prophylaxis (AP) in lung transplant recipients has been shown to reduce the composite end-point of death or chronic lung allograft dysfunction (CLAD) onset but without a clear effect on overall survival. Our program began using AP in 2010. We sought to evaluate the association between AP and survival and the risk of CLAD and baseline lung allograft dysfunction (BLAD). METHODS We studied double lung recipients transplanted between 2004 and 2016. We defined AP as chronic use of azithromycin initiated before CLAD onset. We analyzed the association between AP and death or retransplant using Cox regression with adjustment for potential confounders. We further used Cox and logistic models to assess the relationship between AP and post-transplant CLAD onset and BLAD, respectively. RESULTS A total of 445 patients were included, and 344 (77%) received AP (median time from transplant: 51 days). Patients receiving AP were more likely to receive induction with interleukin-2 receptor antagonists (57% vs 35%; p < 0.001). AP was associated with improved survival (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.42-0.82; p = 0.0020) in our fully adjusted model, with a reduced adjusted risk of BLAD (odds ratio: 0.53; 95% CI: 0.33-0.85; p = 0.0460) but no clear reduction in the adjusted risk of CLAD (HR: 0.69; 95% CI: 0.47-1.03; p = 0.0697). CONCLUSIONS AP is associated with improved survival after lung transplantation, potentially through improved baseline function. These findings build on prior trial results and suggest that AP is beneficial for lung transplant recipients.
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Affiliation(s)
- David Li
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Qiuli Duan
- Health Services Statistical & Analytical Methods, Alberta Health Services, Edmonton, Alberta, Canada
| | - Justin Weinkauf
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ali Kapasi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alim Hirji
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dale Lien
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Steven Meyer
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Bryce Laing
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Kieran Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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175
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Chen R, Wang L, Koch T, Curtis V, Yin-DeClue H, Handley SA, Shan L, Holtzman MJ, Castro M, Wang L. Sex effects in the association between airway microbiome and asthma. Ann Allergy Asthma Immunol 2020; 125:652-657.e3. [PMID: 32931909 DOI: 10.1016/j.anai.2020.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sex differences exist in asthma susceptibility and severity. Accumulating evidence has linked airway microbiome dysbiosis to asthma, and airway microbial communities have been found to differ by sex. However, whether sex modifies the link between airway microbiome and asthma has not been investigated. OBJECTIVE To evaluate sex effects in the association between airway microbiome and asthma. METHODS We analyzed induced sputum samples from 47 subjects (n = 23 patients with asthma and n = 24 normal controls) using 16S ribosomal RNA gene sequencing methods. The bacterial composition was analyzed for sex differences. Bacterial associations with asthma were assessed for each sex at the core taxa and genus levels. RESULTS The microbiome in induced sputum differed in women vs men at the community level. A total of 5 core bacterial taxa were found in all samples. No sex-specific core taxa were detected. The most abundant core taxon, Streptococcus salivarius, was significantly enriched in women than in men (P = .02). Within each sex, individuals with relatively lower abundance of S salivarius were more likely to have asthma (P = .006). For both sexes, increased Lactobacillus species were found in sputum samples of patients with patients compared with normal controls (adjusted P = .01). Haemophilus species were associated with asthma in men and not in women. CONCLUSION The airway microbiome differed by sex, and sex effects exist in the association of airway microbial markers and asthma. Future airway microbiome studies may yield better resolution if the context of specific sex is considered. The airway microbiome is a potential mechanism driving sex differences in asthma.
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Affiliation(s)
- Renjin Chen
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Leran Wang
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Tammy Koch
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Vanessa Curtis
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Huiqing Yin-DeClue
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Scott A Handley
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri; Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri
| | - Liang Shan
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Michael J Holtzman
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mario Castro
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Leyao Wang
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
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176
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Pérez de Llano L, Miravitlles M, Golpe R, Alvarez-Gutiérrez FJ, Cisneros C, Almonacid C, Martinez-Moragon E, Gonzalez-Barcala FJ, Ramos-Barbón D, Plaza V, Lopez-Campos JL, de-Torres JP, Casanova C, Garcia Rivero JL, Rodriguez Hermosa J, Calle Rubio M, Soler-Cataluña JJ, Cosio BG. A Proposed Approach to Chronic Airway Disease (CAD) Using Therapeutic Goals and Treatable Traits: A Look to the Future. Int J Chron Obstruct Pulmon Dis 2020; 15:2091-2100. [PMID: 32943862 PMCID: PMC7481271 DOI: 10.2147/copd.s263430] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022] Open
Abstract
Chronic airflow obstruction affects a wide range of airway diseases, the most frequent of which are asthma, COPD, and bronchiectasis; they are clearly identifiable in their extremes, but quite frequently overlap in some of their pathophysiological and clinical characteristics. This has generated the description of new mixed or overlapping disease phenotypes with no clear biological grounds. In this special article, a group of experts provides their perspective and proposes approaching the treatment of chronic airway disease (CAD) through the identification of a series of therapeutic goals (TG) linked to treatable traits (TT) - understood as clinical, physiological, or biological characteristics that are quantifiable using biomarkers. This therapeutic approach needs validating in a clinical trial with the strategy of identification of TG and treatment according to TT for each patient independently of their prior diagnosis.
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Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, University Hospital Lucus Augusti, Lugo, EOXI Cervo, Lugo, Monforte, Spain
| | - Marc Miravitlles
- Pneumology Service, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBERES, Barcelona, Spain
| | - Rafael Golpe
- Pneumology Service, University Hospital Lucus Augusti, Lugo, EOXI Cervo, Lugo, Monforte, Spain
| | | | - Carolina Cisneros
- Pneumology Service, La Princesa University Hospital, Madrid, Research Institute La Princesa IIP, Madrid, Spain
| | - Carlos Almonacid
- Pneumology Service, Ramón y Cajal Hospital (Ramon y Cajal Health Research Institute, IRYCIS), Madrid, Spain
| | | | - Francisco-Javier Gonzalez-Barcala
- Faculty of Medicine at the University of Santiago de Compostela, Pneumology Service of the University Clinical Hospital of Santiago de Compostela, CIBERES, Santiago de Compostela, Spain
| | - David Ramos-Barbón
- Pneumology Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Vicente Plaza
- Pneumology Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Juan Pablo de-Torres
- Division of Respirology and Sleep Medicine, Queen's University, Canada, ON, Canada
| | - Ciro Casanova
- Pneumology Service, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz De Tenerife, Spain
| | | | - Juan Rodriguez Hermosa
- Pneumology Service and Faculty of Medicine, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - Myriam Calle Rubio
- Pneumology Service and Faculty of Medicine, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | | | - Borja G Cosio
- Pneumology Service, Son Espases University Hospital, IdISBa, CIBERES, Clínica Quirón-Rotger, Palma, Spain
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177
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Alsowaida YS, Almulhim AS, Oh M, Erstad B, Abraham I. Sensorineural hearing loss with macrolide antibiotics exposure: a meta-analysis of the association. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2020; 29:21-28. [PMID: 32871046 DOI: 10.1111/ijpp.12670] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Macrolide antibiotics are among the most commonly used antibiotics; the association of macrolide antibiotics exposure with sensorineural hearing loss (SNHL) has been hypothesized. A systematic search was conducted in PubMed, EMBASE and Cochrane Library from inception to 15 July 2019 to identify studies used macrolide antibiotics for any indication. The results were reported as odds ratio (OR) with 95% confidence interval (CI) using random-effects model to derive the association of macrolide antibiotics exposure with SNHL. The objective of this meta-analysis was to estimate the association of macrolide antibiotics exposure and SNHL from up-to-date evidence. KEY FINDINGS Nine studies met the inclusion criteria. There was no statistically significant association between macrolide antibiotics exposure and SNHL; the OR was 1.20 (95% CI: 0.96 to 1.49). No significant association was found with any of the subgroup meta-analyses. SUMMARY Whilst the frequency of SNHL was higher with macrolide antibiotics exposure compared with controls, overall, no association was found between macrolide antibiotics and SNHL.
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Affiliation(s)
- Yazed Saleh Alsowaida
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA.,Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.,Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail, Saudi Arabia
| | - Abdulaziz Saleh Almulhim
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA.,College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mok Oh
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Brian Erstad
- Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA.,University of Arizona Cancer Center, University of Arizona, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA.,Department of Family and Community Medicine, College of Medicine - Tucson, University of Arizona, Tucson, AZ, USA
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178
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Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a heterogeneous syndrome and may comprise several different phenotypes that are driven by different molecular mechanisms (endotypes). Several different clinical, genetic, and inflammatory phenotypes of COPD have been recognized and this may lead to more precise effective therapies. AREAS COVERED The different clinical phenotypes, including smoking versus nonsmoking COPD, small airway disease versus emphysema, non-exacerbators versus frequent exacerbators are discussed. Rare genetic endotypes (alpha1-antitrypsin deficiency, telomerase polymorphisms), and inflammatory phenotypes (eosinophilic versus neutrophilic) are also recognized in stable and exacerbating patients and have implications for the choice of therapy. EXPERT OPINION Clinical phenotypes have so far not proved to be very useful in selecting more personalized therapy for COPD. Even with genetic endotypes, this has not led to improved therapy. More promising is the recognition that COPD patients who have increased sputum or blood eosinophils tend to have more frequent exacerbations and inhaled corticosteroids are more effective in preventing exacerbation. Increased blood eosinophils have proved to be a useful biomarker now used to target ICS more effectively. Furthermore, COPD patients with low eosinophils are more likely to get pneumonia with ICS and to have lower airway bacterial colonization.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College London , London, UK
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179
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Maekawa T, Tamura H, Domon H, Hiyoshi T, Isono T, Yonezawa D, Hayashi N, Takahashi N, Tabeta K, Maeda T, Oda M, Ziogas A, Alexaki VI, Chavakis T, Terao Y, Hajishengallis G. Erythromycin inhibits neutrophilic inflammation and mucosal disease by upregulating DEL-1. JCI Insight 2020; 5:136706. [PMID: 32603314 DOI: 10.1172/jci.insight.136706] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023] Open
Abstract
Macrolide antibiotics exert antiinflammatory effects; however, little is known regarding their immunomodulatory mechanisms. In this study, using 2 distinct mouse models of mucosal inflammatory disease (LPS-induced acute lung injury and ligature-induced periodontitis), we demonstrated that the antiinflammatory action of erythromycin (ERM) is mediated through upregulation of the secreted homeostatic protein developmental endothelial locus-1 (DEL-1). Consistent with the anti-neutrophil recruitment action of endothelial cell-derived DEL-1, ERM inhibited neutrophil infiltration in the lungs and the periodontium in a DEL-1-dependent manner. Whereas ERM (but not other antibiotics, such as josamycin and penicillin) protected against lethal pulmonary inflammation and inflammatory periodontal bone loss, these protective effects of ERM were abolished in Del1-deficient mice. By interacting with the growth hormone secretagogue receptor and activating JAK2 in human lung microvascular endothelial cells, ERM induced DEL-1 transcription that was mediated by MAPK p38 and was CCAAT/enhancer binding protein-β dependent. Moreover, ERM reversed IL-17-induced inhibition of DEL-1 transcription, in a manner that was dependent not only on JAK2 but also on PI3K/AKT signaling. Because DEL-1 levels are severely reduced in inflammatory conditions and with aging, the ability of ERM to upregulate DEL-1 may lead to a novel approach for the treatment of inflammatory and aging-related diseases.
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Affiliation(s)
- Tomoki Maekawa
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases.,Division of Periodontology, and
| | - Hikaru Tamura
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases.,Division of Periodontology, and
| | - Hisanori Domon
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases
| | - Takumi Hiyoshi
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases
| | | | - Daisuke Yonezawa
- Center for Advanced Oral Science.,Division of Oral Science for Health Promotion, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Naoki Hayashi
- Department of Microbiology and Infection Control Sciences, Kyoto Pharmaceutical University, Yamashina, Japan
| | | | | | - Takeyasu Maeda
- Center for Advanced Oral Science.,Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Masataka Oda
- Department of Microbiology and Infection Control Sciences, Kyoto Pharmaceutical University, Yamashina, Japan
| | - Athanasios Ziogas
- Institute of Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Vasileia Ismini Alexaki
- Institute of Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Triantafyllos Chavakis
- Institute of Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany.,Centre for Cardiovascular Science, Queen's Medical Research Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Yutaka Terao
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases
| | - George Hajishengallis
- Laboratory of Innate Immunity and Inflammation, Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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180
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Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by persistent respiratory symptoms and progressive airflow obstruction. Tobacco smoking is the leading cause but not the only one. A postbronchodilator FEV1-FVC ratio less than 0.70 is required for a diagnosis of COPD. Inhaler therapy is the backbone of treatment and should be complemented by a multifaceted management strategy that includes counseling and pharmacotherapy for smoking cessation, pulmonary rehabilitation, treatment of comorbidities, administration of influenza and pneumococcal immunizations, and prescription of long-term oxygen therapy in hypoxemic patients.
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181
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Alter P, Baker JR, Dauletbaev N, Donnelly LE, Pistenmaa C, Schmeck B, Washko G, Vogelmeier CF. Update in Chronic Obstructive Pulmonary Disease 2019. Am J Respir Crit Care Med 2020; 202:348-355. [PMID: 32407642 PMCID: PMC8054880 DOI: 10.1164/rccm.202002-0370up] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL)
| | - Jonathan R. Baker
- Airway Disease, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nurlan Dauletbaev
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL),Department of Pediatrics, Faculty of Medicine, McGill University, Montreal, Quebec, Canada,Faculty of Medicine and Healthcare, al-Farabi Kazakh National University, Almaty, Kazakhstan; and
| | - Louise E. Donnelly
- Airway Disease, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Carrie Pistenmaa
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bernd Schmeck
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL),Institute for Lung Research, Member of the DZL and of the German Center of Infection Research (DZIF), and,Center for Synthetic Microbiology (SYNMIKRO), Philipps University of Marburg, Marburg, Germany
| | - George Washko
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Claus F. Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL)
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Djamin RS, Talman S, Schrauwen EJA, von Wintersdorff CJH, Wolffs PF, Savelkoul PHM, Uzun S, Kerstens R, van der Eerden MM, Kluytmans JAJW. Prevalence and abundance of selected genes conferring macrolide resistance genes in COPD patients during maintenance treatment with azithromycin. Antimicrob Resist Infect Control 2020; 9:116. [PMID: 32723393 PMCID: PMC7389634 DOI: 10.1186/s13756-020-00783-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/14/2020] [Indexed: 11/16/2022] Open
Abstract
Objectives Maintenance treatment with macrolide antibiotics has shown to be effective in reducing exacerbations in COPD patients. A major concern with prolonged treatment with antibiotics is the development of bacterial resistance. In this study we determined the effect of azithromycin on the development and acquisition of resistance to macrolides in the nasopharyngeal flora in COPD patients. Methods This study was part of the COLUMBUS trial, a randomised, double-blind, placebo-controlled trial to measure the effect of maintenance treatment with azithromycin in 92 COPD patients on the exacerbation rates during a 12-month period. In order to determine resistance to macrolides, we used a targeted metagenomic approach to measure the presence and relative abundance of specific macrolide resistance genes ermB, ermF and mefA in throat samples collected at different time-points during this 12-month period. Results There was no increased risk for acquisition of macrolide resistance genes in the azithromycin group compared to the placebo group in COPD patients. However, loss of the macrolide resistance gene ermB was increased overtime in the placebo treated group compared to the azithromycin group (n = 5 for the placebo group versus n = 0 for the azithromycin group at 12 months; p = 0.012). The change in relative abundance of the three macrolide-resistance genes showed that all but one (ermF) increased during treatment with azithromycin. Conclusions The acquisition rate of macrolide resistance genes in COPD patients treated with azithromycin maintenance therapy was limited, but the relative abundance of macrolide resistance genes increased significantly over time compared to placebo. This study was part of the COLUMBUS trial (Clinicaltrials.gov, NCT00985244).
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Affiliation(s)
- Remco S Djamin
- Department t of Respiratory Medicine, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands
| | - Sander Talman
- Department t of Respiratory Medicine, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands.
| | - Eefje J A Schrauwen
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands.,Academy for Technology and Environmental Health, Avans University of Applied Sciences, Breda, the Netherlands
| | | | - Petra F Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Paul H M Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Sevim Uzun
- Department t of Respiratory Medicine, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands
| | - René Kerstens
- Orion Statistical Consulting BV, Hilvarenbeek, The Netherlands
| | | | - Jan A J W Kluytmans
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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183
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Albertson TE, Pugashetti JV, Chau-Etchepare F, Chenoweth JA, Murin S. Pharmacotherapeutic management of asthma in the elderly patient. Expert Opin Pharmacother 2020; 21:1991-2010. [PMID: 32686969 DOI: 10.1080/14656566.2020.1795131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines. AREAS COVERED A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed. EXPERT OPINION Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Florence Chau-Etchepare
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
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184
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Barjaktarevic IZ, Milstone AP. Nebulized Therapies in COPD: Past, Present, and the Future. Int J Chron Obstruct Pulmon Dis 2020; 15:1665-1677. [PMID: 32764912 PMCID: PMC7367939 DOI: 10.2147/copd.s252435] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/18/2020] [Indexed: 12/31/2022] Open
Abstract
Current guidelines recommend inhalation therapy as the preferred route of drug administration for treating patients with chronic obstructive pulmonary disease (COPD). Inhalation devices consist of nebulizers and handheld inhalers, such as dry-powder inhalers (DPIs), pressurized metered-dose inhalers (pMDIs), and soft mist inhalers (SMIs). Although pMDIs, DPIs and SMIs may be appropriate for most patients with COPD, certain patient populations may have challenges with these devices. Patients who have cognitive, neuromuscular, or ventilatory impairments (and receive limited assistance from caregivers), as well as those with suboptimal peak inspiratory flow may not derive the full benefit from handheld inhalers. A considerable number of patients are not capable of producing a peak inspiratory flow rate to overcome the internal resistance of DPIs. Furthermore, patients may have difficulty coordinating inhalation with device actuation, which is required for pMDIs and SMIs. However, inhalation devices such as spacers and valved holding chambers can be used with pMDIs to increase the efficiency of aerosol delivery. Nebulized treatment provides patients with COPD an alternative administration route that avoids the need for inspiratory flow, manual dexterity, or complex hand-breath coordination. The recent approval of two nebulized long-acting muscarinic antagonists has added to the extensive range of nebulized therapies in COPD. Furthermore, with the availability of quieter and more portable nebulizer devices, nebulization may be a useful treatment option in the management of certain patient populations with COPD. The aim of this narrative review was to highlight recent updates and the treatment landscape in nebulized therapy and COPD. We first discuss the pathophysiology of patients with COPD and inhalation device considerations. Second, we review the updates on recently approved and newly marketed nebulized treatments, nebulized treatments currently in development, and technological advances in nebulizer devices. Finally, we discuss the current applications of nebulized therapy in patients with COPD.
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Affiliation(s)
- Igor Z Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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185
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Whittaker Brown SA, Braman S. Recent Advances in the Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Med Clin North Am 2020; 104:615-630. [PMID: 32505256 DOI: 10.1016/j.mcna.2020.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic obstructive pulmonary disease is a chronic, irreversible obstructive lung disease that results from exposure to noxious stimuli. Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) usually result from viral or bacterial respiratory infections, but may also result from exposure to environmental pollution. AECOPD are associated with functional decline, increased risk of subsequent exacerbations, and death. Despite the poor prognosis of AECOPD, patients are empowered through self-management programs in their battle against this lethal disease. Morbidity and mortality of chronic obstructive pulmonary disease hospitalizations are reduced by implementing standardized treatment modalities outlined in this article throughout the hospitalization and beyond.
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Affiliation(s)
- Stacey-Ann Whittaker Brown
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA.
| | - Sidney Braman
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
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186
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Weiss A, Porter S, Rozenberg D, O'Connor E, Lee T, Balter M, Wentlandt K. Chronic Obstructive Pulmonary Disease: A Palliative Medicine Review of the Disease, Its Therapies, and Drug Interactions. J Pain Symptom Manage 2020; 60:135-150. [PMID: 32004618 DOI: 10.1016/j.jpainsymman.2020.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/16/2020] [Indexed: 12/12/2022]
Abstract
Despite significant advances in treatment, chronic obstructive pulmonary disease (COPD) remains a chronic and progressive disease that frequently leads to premature mortality. COPD is associated with a constellation of significant symptoms, including dyspnea, cough, wheezing, pain, fatigue, anxiety, depression, and insomnia, and is associated with increased morbidity. Palliative care is appropriate to support these patients. However, historically, palliative care has focused on supporting patients with malignant disease, rather than progressive chronic diseases such as COPD. Therapies for COPD often result in functional and symptomatic improvements, including health-related quality of life (HRQL), and palliative care may further improve symptoms and HRQL. Provision of usual palliative care therapies for this patient population requires understanding the pathogenesis of COPD and common disease-targeted pharmacotherapies, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes COPD and current targeted therapies and their effects on symptoms, exercise tolerance, HRQL, and survival. It is important to note that medications commonly used for symptom management in palliative care can interact with COPD medications resulting in increased risk of adverse effects, enhanced toxicity, or changes in clearance of medications. To address this, we review pharmacologic interactions with and precautions related to use of COPD therapies in conjunction with commonly used palliative care medications.
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Affiliation(s)
- Andrea Weiss
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Porter
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- Division of Respirology and Lung Transplantation, Department of Medicine, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Erin O'Connor
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University Health Network, and University of Toronto, Toronto, Ontario, Canada
| | - Tiffany Lee
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Meyer Balter
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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187
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Abstract
Azithromycin (AZM) has been used to treat chronic inflammatory airway diseases because it regulates cell–cell contact between airway epithelial cells. Airway mucus hypersecretion is an important component of chronic respiratory diseases. Mucin 5AC (MUC5AC) is the major mucin produced by airway epithelial cells, and hypersecretion of MUC5AC is a sign of various pulmonary inflammatory diseases. Recently, it was found that matrix metallopeptidase 9 is involved in mucus hypersecretion. Moreover, AZM can inhibit the ability of TNF-α-to induce interleukin (IL)-8 production. This review focuses on the effects on AZM that may be beneficial in inhibiting MUC5AC, matrix metalloprotease-9 and IL-8 production in airway epithelial cells. In addition, recent studies have begun to assess activation of mitogen-activated protein kinase (MAPK) signaling pathways in response to AZM. Understanding these new developments may be helpful for clinicians.
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Affiliation(s)
- Jie Yang
- Central Laboratory, Danyang People's Hospital of Jiangsu Province, Danyang, Jiangsu, China
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188
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Wang Y, Ninaber DK, van Schadewijk A, Hiemstra PS. Tiotropium and Fluticasone Inhibit Rhinovirus-Induced Mucin Production via Multiple Mechanisms in Differentiated Airway Epithelial Cells. Front Cell Infect Microbiol 2020; 10:278. [PMID: 32637364 PMCID: PMC7318795 DOI: 10.3389/fcimb.2020.00278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/12/2020] [Indexed: 01/16/2023] Open
Abstract
Human rhinoviruses (HRVs) are associated with acute exacerbations in patients with chronic obstructive pulmonary disease (COPD) and asthma, which are accompanied by mucus hypersecretion. Whereas, various studies have shown that HRVs increase epithelial mucin production and thus may directly contribute to mucus hypersecretion. The effects of drugs used in the treatment of COPD and asthma on HRV-induced mucin production in epithelial cell cultures have not been studied. In the present study, we assessed effects of HRVs on mucin production and secretion in well-differentiated primary human bronchial epithelial cells (PBEC) and studied the effect of the inhaled corticosteroid fluticasone propionate and the long-acting muscarinic antagonist tiotropium bromide on this process. Differentiated PBEC that were cultured at the air-liquid interface (ALI-PBEC) were infected with HRV-A16 and HRV-1B. Quantitative PCR, immunofluorescence staining, ELISA, periodic acid-Schiff (PAS) staining and immunostaining assays were used to assess the effects of HRV infection. Here we demonstrate that both HRV-A16 and HRV-1B increased mucin (MUC5AC and MUC5B) gene expression and protein release. When exploring this in more detail in HRV-A16-infected epithelial cells, mucin expression was found to be accompanied by increases in expression of SAM-pointed domain-containing Ets-like factor (SPDEF) and SPDEF-regulated genes known to be involved in the regulation of mucin production. We also found that pre-treatment with the purinergic P2R antagonist suramin inhibits HRV-enhanced MUC5AC expression and protein release, implicating involvement of purinergic signaling by extracellular ATP. We furthermore found that both fluticasone and tiotropium decreased HRV-induced mucin production without affecting viral replication, and obtained evidence to suggest that the inhibitory effect of fluticasone involved modulation of SPDEF-regulated genes and extracellular ATP release. These data show that both tiotropium and fluticasone inhibit HRV-induced epithelial mucin production independent of viral clearance, and thus provide insight into the mechanisms underlying beneficial effects of tiotropium and fluticasone in the treatment of COPD, asthma and accompanying exacerbations in these patients. Furthermore, our findings provide additional insight into the mechanisms by which HRV increases epithelial mucin production.
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Affiliation(s)
- Ying Wang
- Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
| | - Dennis K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Pieter S Hiemstra
- Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
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189
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Pani A, Lauriola M, Romandini A, Scaglione F. Macrolides and viral infections: focus on azithromycin in COVID-19 pathology. Int J Antimicrob Agents 2020; 56:106053. [PMID: 32534189 PMCID: PMC7286256 DOI: 10.1016/j.ijantimicag.2020.106053] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 12/12/2022]
Abstract
It is necessary to quickly find therapeutic options for treating novel SARS-CoV2 Azithromycin has been demonstrated to have antiviral and immunomodulatory effects, which could be effective in the hyper-inflammatory syndrome caused by SARS-CoV2 Azithromycin has also shown clinical efficacy in respiratory distress syndrome and viral infections Preliminary results regarding the efficacy of the combination of azithromycin and hydroxychloroquine in COVID-19 are conflicting There are some concerns regarding the association of azithromycin and hydroxychloroquine because of QT prolongation Further studies have to be performed to investigate the safety and efficacy of azithromycin and the combination with hydroxychloroquine in COVID-19
The emergence of the new COVID-19 virus is proving to be a challenge in seeking effective therapies. Since the most severe clinical manifestation of COVID-19 appears to be a severe acute respiratory syndrome, azithromycin has been proposed as a potential treatment. Azithromycin is known to have immunomodulating and antiviral properties. In vitro studies have demonstrated the capacity of azithromycin in reducing production of pro-inflammatory cytokines such as IL-8, IL-6, TNF alpha, reduce oxidative stress, and modulate T-helper functions. At the same time there are multiple clinical evidences of the role of azithromycin in acute respiratory distress syndrome and against Middle East Respiratory syndrome (MERS). Some preliminary evidence has demonstrated controversial results regarding efficacy of azithromycin in combination with hydroxychloroquine in COVID-19. First, a French trial demonstrated 100% virological negativizing of six patients treated with azithromycin plus hydroxychloroquine vs. 57.1% of patients treated with only hydroxychloroquine and 12.5% of the control group (P < 0.05). On the other hand, another case series revealed no efficacy at all on 11 patients treated with the same combination and doses. Furthermore, there are some concerns regarding the association of azithromycin and hydroxychloroquine because of potential QT prolongation. In fact, both drugs have this as a potential side effect and evidence regarding the safe use of this combination is controversial. Despite the necessity to quickly find solutions for COVID-19, extreme caution must be used in evaluating the risk-benefit balance. However, based on preclinical and clinical evidence and some preliminary results in COVID-19, azithromycin could have potential in the fight against this new disease.
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Affiliation(s)
- Arianna Pani
- Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy; Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Alessandra Romandini
- Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy; Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Scaglione
- Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy; Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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190
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Tashkin DP, Amin AN, Kerwin EM. Comparing Randomized Controlled Trials and Real-World Studies in Chronic Obstructive Pulmonary Disease Pharmacotherapy. Int J Chron Obstruct Pulmon Dis 2020; 15:1225-1243. [PMID: 32581529 PMCID: PMC7276323 DOI: 10.2147/copd.s244942] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
Analytic epidemiological studies cover a large spectrum of study methodologies, ranging from noninterventional observational studies (population-based, case-control, or cohort studies) to interventional studies (clinical trials). Herein, we review the different research methodologies or study designs and discuss their advantages and disadvantages in the context of chronic obstructive pulmonary disease (COPD) pharmacotherapy. Although randomized controlled trials (RCTs) are considered the "gold standard" for evaluating the efficacy and safety of an intervention, observational studies conducted in a real-world scenario are useful in providing evidence on the effectiveness of the intervention in clinical practice; understanding both efficacy and effectiveness is important from the clinician's perspective. Pragmatic clinical trials that use real-world data while retaining randomization bridge the gap between explanatory RCTs and noninterventional observational studies. Overall, different study designs have their associated advantages and disadvantages; together, findings from all types of studies bring about progress in clinical research as elucidated through examples from COPD research in this paper.
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Affiliation(s)
- Donald P Tashkin
- The Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Alpesh N Amin
- Department of Medicine, School of Medicine University of California, Irvine, CA, USA
| | - Edward M Kerwin
- Crisor, LLC Clinical Research Institute of Southern Oregon, Medford, OR, USA
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191
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Burns RB, Anandaiah A, Rice MB, Smetana GW. Should You Recommend Inhaled Corticosteroids for This Patient With Chronic Obstructive Pulmonary Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2020; 172:735-742. [PMID: 32479149 DOI: 10.7326/m20-1058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Approximately 12 million adults in the United States receive a diagnosis of chronic obstructive pulmonary disease (COPD) each year, and it is the fourth leading cause of death. Chronic obstructive pulmonary disease refers to a group of diseases that cause airflow obstruction and a constellation of symptoms, including cough, sputum production, and shortness of breath. The main risk factor for COPD is tobacco smoke, but other environmental exposures also may contribute. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2020 Report aims to provide a nonbiased review of the current evidence for the assessment, diagnosis, and treatment of patients with COPD. To date, no conclusive evidence exists that any existing medications for COPD modify mortality. The mainstay of treatment for COPD is inhaled bronchodilators, whereas the role of inhaled corticosteroids is less clear. Inhaled corticosteroids have substantial risks, including an increased risk for pneumonia. Here, 2 experts, both pulmonologists, reflect on the care of a woman with severe COPD, a 50-pack-year smoking history, frequent COPD exacerbations, and recurrent pneumonia. They consider the indications for inhaled corticosteroids in COPD, when inhaled corticosteroids should be withdrawn, and what other treatments are available.
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Affiliation(s)
- Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., A.A., M.B.R., G.W.S.)
| | - Asha Anandaiah
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., A.A., M.B.R., G.W.S.)
| | - Mary B Rice
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., A.A., M.B.R., G.W.S.)
| | - Gerald W Smetana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., A.A., M.B.R., G.W.S.)
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192
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Lopez-Campos JL, Miravitlles M, de la Rosa Carrillo D, Cantón R, Soler-Cataluña JJ, Martinez-Garcia MA. Current Challenges in Chronic Bronchial Infection in Patients with Chronic Obstructive Pulmonary Disease. J Clin Med 2020; 9:E1639. [PMID: 32481769 PMCID: PMC7356662 DOI: 10.3390/jcm9061639] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/14/2022] Open
Abstract
Currently, chronic obstructive pulmonary disease (COPD) patients and their physicians face a number of significant clinical challenges, one of which is the high degree of uncertainty related to chronic bronchial infection (CBI). By reviewing the current literature, several challenges can be identified, which should be considered as goals for research. One of these is to establish the bases for identifying the biological and clinical implications of the presence of potentially pathogenic microorganisms in the airways that should be more clearly elucidated according to the COPD phenotype. Another urgent area of research is the role of long-term preventive antibiotics. Clinical trials need to be carried out with inhaled antibiotic therapy to help clarify the profile of those antibiotics. The role of inhaled corticosteroids in patients with COPD and CBI needs to be studied to instruct the clinical management of these patients. Finally, it should be explored and confirmed whether a suitable antimicrobial treatment during exacerbations may contribute to breaking the vicious circle of CBI in COPD. The present review addresses the current state of the art in these areas to provide evidence which will enable us to progressively plan better healthcare for these patients.
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Affiliation(s)
- José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, 41013 Seville, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.M.); (M.A.M.-G.)
| | - Marc Miravitlles
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.M.); (M.A.M.-G.)
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | | | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain;
| | | | - Miguel Angel Martinez-Garcia
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.M.); (M.A.M.-G.)
- Pneumology Department, Universitary and Polytechnic La Fe Hospital, 46015 Valencia, Spain
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193
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Leitao Filho FS, Mattman A, Schellenberg R, Criner GJ, Woodruff P, Lazarus SC, Albert RK, Connett J, Han MK, Gay SE, Martinez FJ, Fuhlbrigge AL, Stoller JK, MacIntyre NR, Casaburi R, Diaz P, Panos RJ, Cooper JA, Bailey WC, LaFon DC, Sciurba FC, Kanner RE, Yusen RD, Au DH, Pike KC, Fan VS, Leung JM, Man SFP, Aaron SD, Reed RM, Sin DD. Serum IgG Levels and Risk of COPD Hospitalization: A Pooled Meta-analysis. Chest 2020; 158:1420-1430. [PMID: 32439504 DOI: 10.1016/j.chest.2020.04.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hypogammaglobulinemia (serum IgG levels < 7.0 g/L) has been associated with increased risk of COPD exacerbations but has not yet been shown to predict hospitalizations. RESEARCH QUESTION To determine the relationship between hypogammaglobulinemia and the risk of hospitalization in patients with COPD. STUDY DESIGN AND METHODS Serum IgG levels were measured on baseline samples from four COPD cohorts (n = 2,259): Azithromycin for Prevention of AECOPD (MACRO, n = 976); Simvastatin in the Prevention of AECOPD (STATCOPE, n = 653), Long-Term Oxygen Treatment Trial (LOTT, n = 354), and COPD Activity: Serotonin Transporter, Cytokines and Depression (CASCADE, n = 276). IgG levels were determined by immunonephelometry (MACRO; STATCOPE) or mass spectrometry (LOTT; CASCADE). The effect of hypogammaglobulinemia on COPD hospitalization risk was evaluated using cumulative incidence functions for this outcome and deaths (competing risk). Fine-Gray models were performed to obtain adjusted subdistribution hazard ratios (SHR) related to IgG levels for each study and then combined using a meta-analysis. Rates of COPD hospitalizations per person-year were compared according to IgG status. RESULTS The overall frequency of hypogammaglobulinemia was 28.4%. Higher incidence estimates of COPD hospitalizations were observed among participants with low IgG levels compared with those with normal levels (Gray's test, P < .001); pooled SHR (meta-analysis) was 1.29 (95% CI, 1.06-1.56, P = .01). Among patients with prior COPD admissions (n = 757), the pooled SHR increased to 1.58 (95% CI, 1.20-2.07, P < .01). The risk of COPD admissions, however, was similar between IgG groups in patients with no prior hospitalizations: pooled SHR = 1.15 (95% CI, 0.86-1.52, P =.34). The hypogammaglobulinemia group also showed significantly higher rates of COPD hospitalizations per person-year: 0.48 ± 2.01 vs 0.29 ± 0.83, P < .001. INTERPRETATION Hypogammaglobulinemia is associated with a higher risk of COPD hospital admissions.
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Affiliation(s)
- Fernando Sergio Leitao Filho
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andre Mattman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert Schellenberg
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Prescott Woodruff
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Stephen C Lazarus
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Meilan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Steven E Gay
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Anne L Fuhlbrigge
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Neil R MacIntyre
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Richard Casaburi
- Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Philip Diaz
- Department of Internal Medicine, Ohio State University, Columbus, OH
| | - Ralph J Panos
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J Allen Cooper
- Birmingham VA Medical Center, Birmingham, AL; Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - William C Bailey
- Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - David C LaFon
- Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - Frank C Sciurba
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Richard E Kanner
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine in Saint Louis, Saint Louis, MO
| | - David H Au
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA
| | - Kenneth C Pike
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA
| | - Vincent S Fan
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle, WA
| | - Janice M Leung
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shu-Fan Paul Man
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shawn D Aaron
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert M Reed
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Don D Sin
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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194
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Gollob MH. COVID-19, Clinical Trials, and QT-Prolonging Prophylactic Therapy in Healthy Subjects: First, Do No Harm. J Am Coll Cardiol 2020; 75:3184-3186. [PMID: 32407770 PMCID: PMC7213956 DOI: 10.1016/j.jacc.2020.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Michael H Gollob
- Inherited Arrhythmia and Cardiomyopathy Program, Arrhythmia Service, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
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195
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Efficacy and safety of azithromycin maintenance therapy in primary ciliary dyskinesia (BESTCILIA): a multicentre, double-blind, randomised, placebo-controlled phase 3 trial. THE LANCET RESPIRATORY MEDICINE 2020; 8:493-505. [DOI: 10.1016/s2213-2600(20)30058-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022]
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196
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Sadatsafavi M, Mansournia MA, Gustafson P. A threshold-free summary index for quantifying the capacity of covariates to yield efficient treatment rules. Stat Med 2020; 39:1362-1373. [PMID: 31998998 DOI: 10.1002/sim.8481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 11/07/2019] [Accepted: 12/20/2019] [Indexed: 11/09/2022]
Abstract
When data on treatment assignment, outcomes, and covariates from a randomized trial are available, a question of interest is to what extent covariates can be used to optimize treatment decisions. Statistical hypothesis testing of covariate-by-treatment interaction is ill-suited for this purpose. The application of decision theory results in treatment rules that compare the expected benefit of treatment given the patient's covariates against a treatment threshold. However, determining treatment threshold is often context-specific, and any given threshold might seem arbitrary when the overall capacity towards predicting treatment benefit is of concern. We propose the Concentration of Benefit index (Cb ), a threshold-free metric that quantifies the combined performance of covariates towards finding individuals who will benefit the most from treatment. The construct of the proposed index is comparing expected treatment outcomes with and without knowledge of covariates when one of a two randomly selected patients is to be treated. We show that the resulting index can also be expressed in terms of the integrated efficiency of individualized treatment decision over the entire range of treatment thresholds. We propose parametric and semiparametric estimators, the latter being suitable for out-of-sample validation and correction for optimism. We used data from a clinical trial to demonstrate the calculations in a step-by-step fashion. The proposed index has intuitive and theoretically sound interpretation and can be estimated with relative ease for a wide class of regression models. Beyond the conceptual developments, various aspects of estimation and inference for such a metric need to be pursued in future research. R code that implements the method for a variety of regression models is provided at (https://github.com/msadatsafavi/txBenefit).
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Affiliation(s)
- Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Paul Gustafson
- Department of Statistics, University of British Columbia, Vancouver, Canada
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197
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Smith D, Du Rand I, Addy CL, Collyns T, Hart SP, Mitchelmore PJ, Rahman NM, Saggu R. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax 2020; 75:370-404. [PMID: 32303621 DOI: 10.1136/thoraxjnl-2019-213929] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- David Smith
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
| | | | - Charlotte Louise Addy
- Centre for Medical Education, Queens University Belfast, Regional Respiratory Centre, Belfast City Hospital, Belfast, UK
| | - Timothy Collyns
- Medical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon Paul Hart
- Cardiovascular and Respiratory Studies, Hull York Medical School/University of Hull, Hull, UK
| | - Philip J Mitchelmore
- Institute of Biomedical and Clinical Science, College of Medicine & Health, University of Exeter, Exeter, UK.,Department of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit and Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Ravijyot Saggu
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
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198
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Bremmer DN, Moffa MA, Ma K, Bean HR, Snatchko J, Trienski TL, Watson C, Walsh TL. Acute Exacerbations of Chronic Obstructive Pulmonary Disease With a Low Procalcitonin Concentration: Impact of Antibiotic Therapy. Clin Infect Dis 2020; 68:725-730. [PMID: 29982350 DOI: 10.1093/cid/ciy552] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 06/29/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Patients admitted with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) often are prescribed antibiotics. Studies have shown that the use of procalcitonin (PCT) to guide the decision to initiate antibiotic therapy in AECOPD has resulted in less antibiotic use and similar outcomes compared with standard of care. We evaluated patients with AECOPD and low PCT concentrations to determine whether antibiotic therapy was associated with improved outcomes. METHODS We retrospectively evaluated adult patients admitted with AECOPD who had a peak PCT concentration <0.25 µg/mL. Patients were evaluated based on their antibiotic exposure: ≤24 hours vs >24 hours. We also evaluated outcomes based upon the duration of azithromycin therapy: ≤24 hours vs >24 hours. The primary outcome was all-cause 30-day readmissions. Secondary outcomes included length of stay (LOS) and COPD-related 30-day readmissions. RESULTS One hundred sixty-one and 195 patients received ≤24 hours vs >24 hours of antibiotic therapy, respectively. The cohort with ≤24 hours of antibiotics had a shorter LOS (2.8 vs 3.7 days; P = .01). There were no differences in all-cause 30-day readmissions (15.5% vs 17.4%; P = .63) or COPD-related 30-day readmissions (11.2% vs 12.3%; P = .74). Additionally, patients receiving ≤24 hours of azithromycin had a shorter LOS (3.0 vs 3.8 days; P = .002) and there were no differences in all-cause 30-day readmissions (16.2% vs 17.1%; P = .82) or COPD-related 30-day readmissions (11.9% vs 11.6%; P = .94). CONCLUSIONS For adult patients hospitalized with nonsevere AECOPD and low PCT concentrations, antibiotic therapy beyond 24 hours did not improve outcomes.
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Affiliation(s)
- Derek N Bremmer
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network
| | - Matthew A Moffa
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network.,Division of Infectious Diseases, Western Pennsylvania Hospital, Allegheny Health Network
| | - Kiet Ma
- Division of Pulmonary Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Holly R Bean
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network.,Division of Infectious Diseases, Western Pennsylvania Hospital, Allegheny Health Network
| | - Joseph Snatchko
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Tamara L Trienski
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network
| | - Courtney Watson
- Center for Inclusion Health, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Thomas L Walsh
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network.,Division of Infectious Diseases, Western Pennsylvania Hospital, Allegheny Health Network
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199
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Shteinberg M, Flume PA, Chalmers JD. Is bronchiectasis really a disease? Eur Respir Rev 2020; 29:29/155/190051. [PMID: 31996354 DOI: 10.1183/16000617.0051-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/31/2019] [Indexed: 11/05/2022] Open
Abstract
The definition of a disease requires that distinguishing signs and symptoms are present that are common, and that the constellation of signs and symptoms differentiate the condition from other causes. In bronchiectasis, anatomical changes, airways inflammation and airway infection are the distinguishing features that are common to this disease. However, bronchiectasis is a heterogenous disease: signs and symptoms are shared with other airway diseases, there are multiple aetiologies and certain phenotypes of bronchiectasis have distinct clinical and laboratory features that are not common to all people with bronchiectasis. Furthermore, response to therapeutic interventions in clinical trials is not uniform. The concept of bronchiectasis as a treatable trait has been suggested, but this may be too restrictive in view of the heterogeneity of bronchiectasis. It is our opinion that bronchiectasis should be defined as a disease in its own right, but one that shares several pathophysiological features and "treatable traits" with other airway diseases. These traits define the large heterogeneity in the pathogenesis and clinical features and suggest a more targeted approach to therapy.
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Affiliation(s)
- Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel .,Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Patrick A Flume
- Dept of Medicine and Dept of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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200
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Non-CF bronchiectasis: Orphan disease no longer. Respir Med 2020; 166:105940. [PMID: 32250872 DOI: 10.1016/j.rmed.2020.105940] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/13/2020] [Accepted: 03/18/2020] [Indexed: 02/08/2023]
Abstract
Bronchiectasis is a complex, chronic respiratory condition, characterized by frequent cough and exertional dyspnea due to a range of conditions that include inherited mucociliary defects, inhalational airway injury, immunodeficiency states and prior respiratory infections. For years, bronchiectasis was classified as either being caused by cystic fibrosis or non-cystic fibrosis. Non-cystic fibrosis bronchiectasis, once considered an orphan disease, is more prevalent worldwide in part due to greater availability of chest computed tomographic imaging. Identification of the cause of non-cystic fibrosis bronchiectasis with the use of chest imaging, laboratory testing, and microbiologic assessment of airway secretions can lead to initiation of specific therapies aimed at slowing disease progression. Nonpharmacologic therapies such as airway clearance techniques and pulmonary rehabilitation improve patient symptoms. Inhaled corticosteroids should not be routinely prescribed unless concomitant asthma or COPD is present. Inhaled antibiotics prescribed to individuals with >3 exacerbations per year are well tolerated, reduce airway bacteria load and may reduce the frequency of exacerbations. Likewise, chronic macrolide therapy reduces the frequency of exacerbations. Medical therapies for cystic fibrosis bronchiectasis may not be effective in treatment of non-cystic fibrosis bronchiectasis.
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