151
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Hataji O, Nishii Y, Ito K, Sakaguchi T, Saiki H, Suzuki Y, D'Alessandro-Gabazza C, Fujimoto H, Kobayashi T, Gabazza EC, Taguchi O. Smart watch-based coaching with tiotropium and olodaterol ameliorates physical activity in patients with chronic obstructive pulmonary disease. Exp Ther Med 2017; 14:4061-4064. [PMID: 29104624 PMCID: PMC5658686 DOI: 10.3892/etm.2017.5088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 06/21/2017] [Indexed: 11/22/2022] Open
Abstract
Combined therapy with tiotropium and olodaterol notably improves parameters of lung function and quality of life in patients with chronic obstructive pulmonary disease (COPD) compared to mono-components; however, its effect on physical activity is unknown. The present study evaluated whether combination therapy affects daily physical performance in patients with COPD under a smart watch-based encouragement program. This was a non-blinded clinical trial with no randomization or placebo control. A total of 20 patients with COPD were enrolled in the present study. The patients carried an accelerometer for 4 weeks; they received no therapy during the first 2 weeks but they were treated with combined tiotropium and olodaterol under a smart watch-based encouragement program for the last 2 weeks. The pulmonary function test, COPD assessment test, 6-min walk distance and parameters of physical activity were significantly improved (P<0.05) by combination therapy under smart watch-based coaching compared with values prior to treatment. To the best of our knowledge, the present study for the first time provides evidence that smart watch-based coaching in combination with tiotropium and olodaterol may improve daily physical activity in chronic obstructive pulmonary disease.
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Affiliation(s)
- Osamu Hataji
- Respiratory Center, Matsusaka Municipal Hospital, Matsusaka, Mie 515-8544, Japan
| | - Yoichi Nishii
- Respiratory Center, Matsusaka Municipal Hospital, Matsusaka, Mie 515-8544, Japan
| | - Kentaro Ito
- Respiratory Center, Matsusaka Municipal Hospital, Matsusaka, Mie 515-8544, Japan
| | - Tadashi Sakaguchi
- Respiratory Center, Matsusaka Municipal Hospital, Matsusaka, Mie 515-8544, Japan
| | - Haruko Saiki
- Respiratory Center, Matsusaka Municipal Hospital, Matsusaka, Mie 515-8544, Japan
| | - Yuta Suzuki
- Respiratory Center, Matsusaka Municipal Hospital, Matsusaka, Mie 515-8544, Japan
| | | | - Hajime Fujimoto
- Department of Pulmonary and Critical Care Medicine, Mie University Faculty and Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Tetsu Kobayashi
- Department of Pulmonary and Critical Care Medicine, Mie University Faculty and Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Esteban C Gabazza
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Osamu Taguchi
- Mental and Physical Health Center, Mie University Faculty and Graduate School of Medicine, Tsu, Mie 514-8507, Japan
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152
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Thomas M, Halpin DMG, Miravitlles M. When is dual bronchodilation indicated in COPD? Int J Chron Obstruct Pulmon Dis 2017; 12:2291-2305. [PMID: 28814857 PMCID: PMC5546730 DOI: 10.2147/copd.s138554] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Inhaled bronchodilator medications are central to the management of COPD and are frequently given on a regular basis to prevent or reduce symptoms. While short-acting bronchodilators are a treatment option for people with relatively few COPD symptoms and at low risk of exacerbations, for the majority of patients with significant breathlessness at the time of diagnosis, long-acting bronchodilators may be required. Dual bronchodilation with a long-acting β2-agonist and long-acting muscarinic antagonist may be more effective treatment for some of these patients, with the aim of improving symptoms. This combination may also reduce the rate of exacerbations compared with a bronchodilator-inhaled corticosteroid combination in those with a history of exacerbations. However, there is currently a lack of guidance on clinical indicators suggesting which patients should step up from mono- to dual bronchodilation. In this article, we discuss a number of clinical indicators that could prompt a patient and physician to consider treatment escalation, while being mindful of the need to avoid unnecessary polypharmacy. These indicators include insufficient symptomatic response, a sustained increased requirement for rescue medication, suboptimal 24-hour symptom control, deteriorating symptoms, the occurrence of exacerbations, COPD-related hospitalization, and reductions in lung function. Future research is required to provide a better understanding of the optimal timing and benefits of treatment escalation and to identify the appropriate tools to inform this decision.
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Affiliation(s)
- Mike Thomas
- Primary Care and Population Sciences, University of Southampton, Southampton
| | - David MG Halpin
- Department of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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153
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Ficker JH, Rabe KF, Welte T. Role of dual bronchodilators in COPD: A review of the current evidence for indacaterol/glycopyrronium. Pulm Pharmacol Ther 2017; 45:19-33. [DOI: 10.1016/j.pupt.2017.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/29/2017] [Accepted: 04/01/2017] [Indexed: 01/22/2023]
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154
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Beeh KM, Burgel PR, Franssen FME, Lopez-Campos JL, Loukides S, Hurst JR, Fležar M, Ulrik CS, Di Marco F, Stolz D, Valipour A, Casserly B, Ställberg B, Kostikas K, Wedzicha JA. How Do Dual Long-Acting Bronchodilators Prevent Exacerbations of Chronic Obstructive Pulmonary Disease? Am J Respir Crit Care Med 2017; 196:139-149. [PMID: 27922741 DOI: 10.1164/rccm.201609-1794ci] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Decreasing the frequency and severity of exacerbations is one of the main goals of treatment for patients with chronic obstructive pulmonary disease. Several studies have documented that long-acting bronchodilators can reduce exacerbation rate and/or severity, and others have shown that combinations of long-acting β2-adrenergic agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) provide greater reductions in exacerbation frequency than either their monocomponents or LABA/inhaled corticosteroid combinations in patients at low and high risk for these events. In this review, small groups of experts critically evaluated mechanisms potentially responsible for the increased benefit of LABA/LAMA combinations over single long-acting bronchodilators or LABA/inhaled corticosteroids in decreasing exacerbation. These included effects on lung hyperinflation and mechanical stress, inflammation, excessive mucus production with impaired mucociliary clearance, and symptom severity. The data assembled and analyzed by each group were reviewed by all authors and combined into this manuscript. Available clinical results support the possibility that effects of LABA/LAMA combinations on hyperinflation, mucociliary clearance, and symptom severity may all contribute to decreasing exacerbations. Although preclinical studies suggest LABAs and LAMAs have antiinflammatory effects, such effects have not been demonstrated yet in patients with chronic obstructive pulmonary disease.
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Affiliation(s)
- Kai M Beeh
- 1 insaf Respiratory Research Institute, Wiesbaden, Germany
| | - Pierre-Regis Burgel
- 2 Department of Respiratory Diseases and Adult Cystic Fibrosis Centre, Hôpital Cochin, AP-HP and Paris Descartes University, Paris, France
| | - Frits M E Franssen
- 3 Department of Research and Education, Centre of Expertise for Chronic Organ Failure, Horn, the Netherlands
| | - Jose Luis Lopez-Campos
- 4 Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, Sevilla, Spain.,5 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Stelios Loukides
- 6 2nd Respiratory Medicine Department, National and Kapodistrian University of Athens Medical School, Attiko University Hospital, Athens, Greece
| | - John R Hurst
- 7 University College London Respiratory, University College London, London, United Kingdom
| | - Matjaž Fležar
- 8 University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | | | - Fabiano Di Marco
- 10 Dipartimento di Scienze della Salute, Università degli Studi di Milano, Ospedale San Paolo, Milan, Italy
| | - Daiana Stolz
- 11 Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Arschang Valipour
- 12 Ludwig-Boltzmann-Institute for Chronic Obstructive Pulmonary Disease and Respiratory Epidemiology, Otto-Wagner-Spital, Vienna, Austria
| | - Brian Casserly
- 13 University Hospital, Limerick, Ireland.,14 Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Björn Ställberg
- 15 Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Jadwiga A Wedzicha
- 17 Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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155
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Singh D, Scuri M, Collarini S, Vezzoli S, Mariotti F, Muraro A, Acerbi D. Bronchodilator efficacy of extrafine glycopyrronium bromide: the Glyco 2 study. Int J Chron Obstruct Pulmon Dis 2017; 12:2001-2014. [PMID: 28744115 PMCID: PMC5511020 DOI: 10.2147/copd.s137659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
An extrafine formulation of the long-acting muscarinic antagonist glycopyrronium bromide (GB) is in development for chronic obstructive pulmonary disease (COPD), in combination with beclometasone dipropionate and formoterol fumarate - a "fixed triple". This two-part study was randomized, double blind, placebo controlled in patients with moderate-to-severe COPD: Part 1: single-dose escalation, GB 12.5, 25, 50, 100 or 200 μg versus placebo; Part 2: repeat-dose (7-day), four-period crossover, GB 12.5, 25 or 50 μg twice daily (BID) versus placebo, with an open-label extension in which all patients received tiotropium 18 μg once daily. On the morning of Day 8 in all five periods, patients also received formoterol 12 μg. In study Part 1, 27 patients were recruited. All GB doses significantly increased from baseline forced expiratory volume in 1 second (FEV1) area under the curve (AUC0-12h) and peak FEV1, with a trend toward greater efficacy with higher GB dose. All adverse events were mild-moderate in severity, with a lower incidence with GB than placebo and no evidence of a dose-response relationship. In study Part 2, of 38 patients recruited, 34 completed the study. Adjusted mean differences from placebo in 12 h trough FEV1 on Day 7 (primary) were 115, 142 and 136 mL for GB 12.5, 25 and 50 μg BID, respectively (all P<0.001). GB 25 and 50 μg BID were superior (P<0.05) to GB 12.5 μg BID for pre-dose morning FEV1 on Day 8. For this endpoint, GB 25 and 50 μg BID were also superior to tiotropium. Compared with Day 7, addition of formoterol significantly increased Day 8 FEV1 peak and AUC0-12h with all GB doses and placebo (all P<0.001). All adverse events were mild-moderate in severity and there was no indication of a dose-related relationship. This study provides initial evidence on bronchodilation, safety and pharmacokinetics of extrafine GB BID. Overall, the results suggest that GB 25 μg BID is the optimal dose in patients with COPD.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation, University Of Manchester, University Hospital of South Manchester, Manchester, UK
| | - Mario Scuri
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Sara Collarini
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Stefano Vezzoli
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Annamaria Muraro
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Daniela Acerbi
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
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156
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The effect of tiotropium in combination with olodaterol on house dust mite-induced allergic airway disease. Pulm Pharmacol Ther 2017; 45:210-217. [PMID: 28687462 DOI: 10.1016/j.pupt.2017.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/12/2017] [Accepted: 06/29/2017] [Indexed: 11/21/2022]
Abstract
One of the major goals of asthma therapy is to maintain asthma control and prevent acute exacerbations. Long-acting bronchodilators are regularly used for the treatment of asthma patients and in clinical studies the anti-cholinergic tiotropium has recently been shown to reduce exacerbations in patients with asthma. So far it is unclear how tiotropium exerts this effect. For this purpose, we designed an allergen-driven rechallenge model of allergic airway inflammation in mice, to assess the effectiveness of tiotropium and the long-acting β-2 adrenoceptor agonist olodaterol on allergen-induced exacerbations of airway disease. Female C57BL/6J mice were sensitized intranasally (i.n.) with 1 μg of house dust mite (HDM) extract followed by a challenge regime (5 consecutive days 10 μg HDM extract i.n.) after one week. Mice were exposed to a secondary challenge five weeks after sensitization and were treated i.n. with different concentrations of tiotropium or olodaterol (1, 10 and 100 μg/kg) or a combination thereof (10 μg/kg each) prior to and during the secondary challenge period. Three days after the last challenge, bronchoalveolar lavage (BAL) fluid and lung tissue were collected for flow cytometry and histologic analysis, respectively. Secondary challenge with HDM extract strongly induced allergic airway disease reflected by inflammatory cell infiltration and goblet cell metaplasia. Treatment with tiotropium, but not with olodaterol reduced tissue inflammation and goblet cell metaplasia in a dose-dependent manner. The combination of tiotropium and olodaterol was more effective in significantly reducing tissue inflammation compared to tiotropium treatment alone, and also led to a decrease in BAL cell counts. These data suggest that in a model of relapsing allergic airway disease tiotropium directly prevents exacerbations by reducing inflammation and mucus production in the airways. In addition, the combination of tiotropium and olodaterol exerts synergistic effects.
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157
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Samp JC, Joo MJ, Schumock GT, Calip GS, Pickard AS, Lee TA. Risk of Cardiovascular and Cerebrovascular Events in COPD Patients Treated With Long-Acting β 2-Agonist Combined With a Long-Acting Muscarinic or Inhaled Corticosteroid. Ann Pharmacother 2017; 51:945-953. [PMID: 28677404 DOI: 10.1177/1060028017719716] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The recent approval of several fixed-dose combination long-acting β2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) products has increased the use of dual bronchodilators in the treatment of chronic obstructive pulmonary disease (COPD). Understanding the comparative safety of this combination is important for informing treatment decisions. OBJECTIVE To compare the risk of cardiovascular and cerebrovascular (CCV) events associated with LABA/LAMA compared with a combination of LABA and inhaled corticosteroid (ICS). METHODS This was a retrospective, observational cohort study using health insurance claims data to identify COPD patients initiating LABA/LAMA or LABA/ICS. CCV outcomes included hospitalizations with a primary diagnosis for acute coronary syndrome, heart failure, cardiac dysrhythmia, stroke, or transient ischemic attack. Patients were followed until they experienced an event, discontinued treatment, initiated medication from the opposite cohort, or lost enrollment. Patients were matched 1:4 on propensity scores, and time to event was compared using Cox proportional hazards models. RESULTS After matching, there were 3842 patients in the LABA/LAMA cohort and 15 225 in the LABA/ICS cohort. Cardiovascular events in the LABA/LAMA cohort were lower than in the LABA/ICS: hazard ratio (HR) = 0.794; 95% CI = 0.623-0.997. No significant difference in the risk of cerebrovascular events (HR = 1.166; 95% CI = 0.653-1.959) was observed. CONCLUSIONS Despite concerns about the CCV effects of LAMA and LABA monotherapy, the LABA/LAMA combination had similar or lower risk of these events in comparison to LABA/ICS. Further studies are recommended to confirm these findings.
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Affiliation(s)
| | - Min J Joo
- 1 University of Illinois at Chicago, IL, USA
| | | | | | | | - Todd A Lee
- 1 University of Illinois at Chicago, IL, USA
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158
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Ichinose M, Minakata Y, Motegi T, Ueki J, Seki T, Anzai T, Takizawa A, Grönke L, Hirata K. Study Design of VESUTO ®: Efficacy of Tiotropium/Olodaterol on Lung Hyperinflation, Exercise Capacity, and Physical Activity in Japanese Patients with Chronic Obstructive Pulmonary Disease. Adv Ther 2017; 34:1622-1635. [PMID: 28537001 PMCID: PMC5504218 DOI: 10.1007/s12325-017-0554-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Indexed: 11/24/2022]
Abstract
Introduction The superiority of tiotropium/olodaterol is demonstrated in improvement of lung function, dyspnea, lung hyperinflation, and quality of life compared with either monotherapy in patients with chronic obstructive pulmonary disease (COPD). Japanese Respiratory Society Guidelines for COPD management include improvement of exercise tolerance and daily physical activity as the treatment goals; however, there is limited evidence in Japanese patients with COPD. Methods A protocol is developed for the VESUTO® study that investigates the efficacy of tiotropium/olodaterol fixed-dose combination (FDC) compared with tiotropium alone on inspiratory capacity (IC, volume from functional residual capacity to total lung capacity), exercise capacity, and daily physical activity in Japanese patients with COPD. Results A total of 180 Japanese patients with COPD, aged ≥40 years will be enrolled into the double-blind, multicenter, active-controlled, crossover study (NCT02629965) and will be randomized to receive either tiotropium/olodaterol FDC or tiotropium for 6 weeks each [two puffs via RESPIMAT® (Boehringer Ingelheim, Ingelheim, Germany) inhaler in the morning]. The primary endpoint is IC at rest measured at 60 min post-dose after 6 weeks treatment. The secondary endpoints include the 6-min walk distance (6MWD) at 90 min post-dose and physical activity measured by the activity monitor in the last 2 weeks of the 6-week treatment periods. Lung function tests will also be assessed after 6 weeks treatment. A mixed-effects model repeated measures approach will be used for the primary and secondary endpoints. Conclusion The VESUTO® study is the first randomized interventional study to investigate exercise capacity (6MWD) and physical activity measured by a 3-axis accelerometer in Japanese patients with COPD. The study could provide additional evidence of long-acting muscarinic antagonist (LAMA) + long-acting β2-agonist (LABA) combination therapy on patients’ physical activities as well as lung function. Trial registration ClinicalTrials.gov: NCT02629965 (registered on December 1, 2015). Funding The VESUTO study was funded by Nippon Boehringer Ingelheim Co., Ltd., Tokyo, Japan. Electronic supplementary material The online version of this article (doi:10.1007/s12325-017-0554-3) contains supplementary material, which is available to authorized users.
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159
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Chen WC, Huang CH, Sheu CC, Chong IW, Chu KA, Chen YC, Tsai JR, Lee CH, Wei YF. Long-acting beta2-agonists versus long-acting muscarinic antagonists in patients with stable COPD: A systematic review and meta-analysis of randomized controlled trials. Respirology 2017; 22:1313-1319. [DOI: 10.1111/resp.13100] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 03/28/2017] [Accepted: 04/26/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Wang-Chun Chen
- Department of Pharmacy; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
| | - Chi-Hsien Huang
- Department of Family Medicine; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
- Center for Evidence-Based Medicine and Center for Meta-Analysis Research; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Department of Internal Medicine, College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Research Center for Environmental Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Inn-Wen Chong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Research Center for Environmental Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Department of Respiratory Therapy and Graduate Institute of Medicine, College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Kuo-An Chu
- Division of Chest Medicine, Department of Internal Medicine; Kaohsiung-Veterans General Hospital; Kaohsiung Taiwan
| | - Yung-Che Chen
- Division of Pulmonary and Critical Care Medicine; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
| | - Jong-Rung Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Research Center for Environmental Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Department of Respiratory Therapy, College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Cheng-Hung Lee
- Division of Chest Medicine, Department of Internal Medicine; National Cheng Kung University Hospital; Tainan Taiwan
| | - Yu-Feng Wei
- Institute of Biotechnology and Chemical Engineering; I-Shou University; Kaohsiung Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
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160
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Lopez-Campos JL, Calero-Acuña C, Márquez-Martín E, Quintana Gallego E, Carrasco-Hernández L, Abad Arranz M, Ortega Ruiz F. Double bronchodilation in chronic obstructive pulmonary disease: a crude analysis from a systematic review. Int J Chron Obstruct Pulmon Dis 2017; 12:1867-1876. [PMID: 28694697 PMCID: PMC5491571 DOI: 10.2147/copd.s132962] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The combination of a long-acting muscarinic antagonist (LAMA) and a long-acting β2-agonist (LABA) in a single inhaler is a viable treatment option for patients with chronic obstructive pulmonary disease (COPD). Here, we systematically review the current knowledge on double bronchodilation for the treatment of COPD, with a specific focus on its efficacy versus placebo and/or monotherapy bronchodilation. METHODS A systematic review of clinical trials investigating LABA/LAMA combination therapies was conducted. Articles were retrieved from PubMed, Embase, and Scopus on June 26, 2016. We specifically selected clinical trials with a randomized controlled or crossover design published in any scientific journal showing the following characteristics: 1) comparison of different LABA/LAMA combinations in a single inhaler for patients with COPD, 2) dose approved in Europe, and 3) focus on efficacy (versus placebo and/or bronchodilator monotherapy) in terms of lung function, respiratory symptoms, or exacerbations. RESULTS We analyzed 26 clinical trials conducted on 24,338 patients. All LABA/LAMA combinations were consistently able to improve lung function compared with both placebo and bronchodilator monotherapy. Improvements in symptoms were also consistent versus placebo, showing some lack of correlation for some clinical end points and combinations versus monotherapy bronchodilation. Albeit being an exploratory end point, exacerbations showed an improvement with LABA/LAMA combinations over placebo in some trials; however, scarce information was available in comparison with bronchodilator monotherapy in most studies. CONCLUSION Our data show consistent improvements for LABA/LAMA combinations, albeit with some variability (depending on the clinical end point, the specific combination, and the comparison group). Clinicians should be aware that these are average differences. All treatments should be tailored at the individual level to optimize clinical outcomes.
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Affiliation(s)
- Jose Luis Lopez-Campos
- Virgen del Rocio University Hospital, Biomedicine Institute of Seville (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Calero-Acuña
- Virgen del Rocio University Hospital, Biomedicine Institute of Seville (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Eduardo Márquez-Martín
- Virgen del Rocio University Hospital, Biomedicine Institute of Seville (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Esther Quintana Gallego
- Virgen del Rocio University Hospital, Biomedicine Institute of Seville (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Carrasco-Hernández
- Virgen del Rocio University Hospital, Biomedicine Institute of Seville (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Maria Abad Arranz
- Virgen del Rocio University Hospital, Biomedicine Institute of Seville (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Francisco Ortega Ruiz
- Virgen del Rocio University Hospital, Biomedicine Institute of Seville (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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161
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Tariq SM, Thomas EC. Maintenance therapy in COPD: time to phase out ICS and switch to the new LAMA/LABA inhalers? Int J Chron Obstruct Pulmon Dis 2017; 12:1877-1882. [PMID: 28694698 PMCID: PMC5491575 DOI: 10.2147/copd.s138006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Long-term maintenance therapy for COPD is evolving rapidly. Dual bronchodilation with new long-acting muscarinic antagonist and long-acting beta-agonist (LAMA/LABA) fixed dose combination inhalers were introduced over the past 2 years. In clinical trials, these inhalers significantly improved lung function (trough forced expiratory volume in 1 second), patient-reported outcomes, and quality of life measures compared with placebo, their respective monocomponents, and tiotropium. The recorded adverse events of these new inhalers were also similar to those of their monocomponents or placebo. There are concerns regarding long-term complications (weight gain, osteoporosis, cataract) and increased risk of community-acquired pneumonia with the use of inhaled corticosteroids (ICS). The new LAMA/LABA inhalers could potentially reduce the use of ICS as part and parcel of maintenance therapy in COPD. Recent studies compared these LAMA/LABA inhalers with ICS/LABA combination inhalers in moderate-to-severe COPD. The results are promising and favor the LAMA/LABA inhalers, especially in the longer duration trials. Furthermore, there is a clearer picture emerging as to the subgroup of COPD patients who may be able to successfully switch from their current ICS/LABA therapy to these new LAMA/LABA inhalers.
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Affiliation(s)
- Syed Mohammad Tariq
- Department of Respiratory Medicine, Luton and Dunstable University Hospital, Luton
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162
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Miravitlles M, Anzueto A, Jardim JR. Optimizing bronchodilation in the prevention of COPD exacerbations. Respir Res 2017; 18:125. [PMID: 28633665 PMCID: PMC5477752 DOI: 10.1186/s12931-017-0601-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/29/2017] [Indexed: 02/03/2023] Open
Abstract
The natural disease course of chronic obstructive pulmonary disease (COPD) is often punctuated by exacerbations: acute events of symptom worsening associated with significant morbidity and healthcare resource utilization; reduced quality of life; and increased risk of hospitalization and death. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend that patients at risk of exacerbations (GOLD Groups C and D) receive a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA)/LAMA combination, respectively, as preferred initial treatments. The latter recommendation is based on recent trial evidence demonstrating the superior efficacy of a fixed-dose LABA/LAMA over an inhaled corticosteroid (ICS)/LABA in exacerbation prevention. ICS in combination with a LABA is also indicated for prevention of exacerbations, but the use of ICS is associated with an increased risk of adverse events such as pneumonia, and offers limited benefits beyond those provided by LABA or LAMA monotherapy. In this review, we examine evidence from a number of pivotal studies of LABAs and LAMAs, administered as monotherapy or as part of dual or triple combination therapy, with a specific focus on their effect on exacerbations. We also discuss a new proposed treatment paradigm for the management of COPD that takes into account this recent evidence and adopts a more cautious approach to the use of ICS. In alignment with GOLD 2017, we suggest that ICS should be reserved for patients with concomitant asthma or in whom exacerbations persist despite treatment with LABA/LAMA.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antonio Anzueto
- University of Texas Health Science Center, and South Texas Veterans Health Care System, San Antonio, TX USA
| | - José R. Jardim
- Respiratory Division, Escola Paulista de Medicina / Federal University de São Paulo, São Paulo, Brazil
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163
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Abstract
Novel pharmacotherapies introduce additional options to providers and patients in how to best treat chronic obstructive pulmonary disease (COPD). Emerging data question the role of inhaled corticosteroids in COPD treatment, particularly as combination dual bronchodilator pharmacotherapies demonstrate robust results. For those maximized on pharmacotherapy with continued dyspnea or exacerbations or both, emerging bronchoscopic procedures may offer additional therapy in select patients. This review focuses on data supporting the use of novel ultra bronchodilators, particularly in combination, and on the role for inhaled corticosteroid withdrawal and new bronchoscopic procedures.
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Affiliation(s)
- Sharon R Rosenberg
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, UK
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, UK
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164
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Singh D, D'Urzo AD, Chuecos F, Muñoz A, Garcia Gil E. Reduction in clinically important deterioration in chronic obstructive pulmonary disease with aclidinium/formoterol. Respir Res 2017; 18:106. [PMID: 28558833 PMCID: PMC5450266 DOI: 10.1186/s12931-017-0583-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/15/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND 'Clinically important deterioration' (CID) is a composite endpoint measuring worsening of the key clinical features of chronic obstructive pulmonary disease (COPD), namely lung function, patient-reported outcomes, and exacerbations. ACLIFORM and AUGMENT were two 24-week, randomized, double-blind, phase III studies assessing twice-daily (BID) aclidinium bromide (AB) 400 μg/formoterol fumarate (FF) 12 μg. This pooled post-hoc analysis assessed the effects of AB/FF 400/12 μg on both first and sustained CID events versus placebo and monotherapies in patients with moderate to severe COPD. METHODS A first CID event was defined as the occurrence of a moderate/severe exacerbation or the worsening from baseline in ≥1 of the following: trough forced expiratory volume in 1 second (FEV1; ≥100 mL), Transition Dyspnea Index (TDI) focal score (≥1 unit), or St George's Respiratory Questionnaire (SGRQ) total score (≥4 units). A 'sustained' CID was defined as a worsening maintained at all subsequent visits from appearance to week 24 or a moderate/severe exacerbation at any time. CID events were assessed at three visits (weeks 4, 12, and 24); trough FEV1 was also measured at weeks 1 and 18. RESULTS AB/FF 400/12 μg reduced the risk of a first CID event by 45% versus placebo (hazard ratio [HR] 0.55, p < 0.001), 18% versus FF 12 μg (HR 0.82, p < 0.01), and 15% versus AB 400 μg (HR 0.85, p < 0.05). Similarly, AB/FF 400/12 μg reduced the risk of a sustained CID event by 48% versus placebo (HR 0.52, p < 0.001) and 22% versus FF 12 μg (HR 0.78, p < 0.01). AB/FF 400/12 μg reduced the risk of a first or sustained CID event for all four components versus placebo (trough FEV1 and TDI, first and sustained CID, all p < 0.001; SGRQ first CID p < 0.001; SGRQ sustained CID, p < 0.01; exacerbations first and sustained CID, both p < 0.05) and TDI and SGRQ versus FF 12 μg (TDI, first and sustained CID both p < 0.05; SGRQ first CID p < 0.01), and SGRQ versus AB 400 μg (first CID, p < 0.05). CONCLUSIONS AB/FF 400/12 μg BID may provide greater airway stability and fewer exacerbations or deteriorations in lung function, health status, or dyspnea compared with placebo or monotherapies. TRIAL REGISTRATION Clinicaltrials.gov NCT01462942 (ACLIFORM); registered 26 October 2011. Clinicaltrials.gov NCT01437397 (AUGMENT); registered 19 September 2011.
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Affiliation(s)
- Dave Singh
- The University of Manchester, Medicines Evaluation Unit, Centre for Respiratory and Allergy Medicine, University Hospital of South Manchester Foundation Trust, Manchester, M23 9QZ, UK.
| | - Anthony D D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Anna Muñoz
- Former employee of AstraZeneca PLC, Barcelona, Spain
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165
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Suissa S, Dell'Aniello S, Ernst P. Concurrent use of long-acting bronchodilators in COPD and the risk of adverse cardiovascular events. Eur Respir J 2017; 49:49/5/1602245. [PMID: 28536251 DOI: 10.1183/13993003.02245-2016] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/09/2017] [Indexed: 11/05/2022]
Abstract
The cardiovascular risk of concurrently using long-acting β2-agonists (LABAs) and anticholinergics (LAMAs) in COPD is uncertain. We assessed the comparative cardiovascular and cerebrovascular safety of adding a second long-acting bronchodilator in patients with COPD.We identified a cohort of COPD patients, new users of LABA or the LAMA tiotropium during 2002-2012, from the UK Clinical Practice Research Datalink. Using high-dimensional propensity scores, each patient adding a second bronchodilator was matched with a patient who remained on monotherapy. Patients were followed for 1 year for the occurrence of acute myocardial infarction (AMI), stroke, heart failure and arrhythmia.The cohorts included up to 31 174 patients adding a bronchodilator matched to 31 174 patients remaining on bronchodilator monotherapy. Adding a long-acting bronchodilator, compared to remaining on monotherapy, was not associated with an increased risk of AMI (hazard ratio (HR) 1.12, 95% CI 0.92-1.36), stroke (HR 0.87, 95% CI 0.69-1.10) or arrhythmia (HR 1.05, 95% CI 0.81-1.36), but the risk was elevated for heart failure (HR 1.16, 95% CI 1.03-1.30).Adding a second long-acting bronchodilator in the real-world-setting treatment of COPD does not increase the risk of most cardiovascular events. The modest increase for heart failure warrants further investigation.
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital, Dept of Epidemiology and Biostatistics, McGill University, Montréal, QC, Canada
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital, Dept of Epidemiology and Biostatistics, McGill University, Montréal, QC, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital, Dept of Epidemiology and Biostatistics, McGill University, Montréal, QC, Canada
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166
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Hanania NA, Tashkin DP, Kerwin EM, Donohue JF, Denenberg M, O'Donnell DE, Quinn D, Siddiqui S, Orevillo C, Maes A, Reisner C. Long-term safety and efficacy of glycopyrrolate/formoterol metered dose inhaler using novel Co-Suspension™ Delivery Technology in patients with chronic obstructive pulmonary disease. Respir Med 2017; 126:105-115. [DOI: 10.1016/j.rmed.2017.03.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 02/04/2023]
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167
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Watz H. Chronic obstructive pulmonary disease: inhale deeply and start to exercise. Eur Respir J 2017; 49:49/4/1700424. [PMID: 28424367 DOI: 10.1183/13993003.00424-2017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
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168
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Abstract
Evidence-based guidelines recommend inhaled long-acting anti-muscarinic agents (LAMAs) as first-line maintenance therapy for symptomatic patients with COPD. Several LAMAs are now available for use either as monotherapy or in combination with other COPD medications, including long-acting β2-agonists (LABAs) or inhaled corticosteroids (ICS). The efficacy and long-term safety of these medications have been evaluated in multiple clinical trials and real-life studies. This review evaluates the evidence available on the safety of existing LAMAs alone or in combination with LABAs and ICS in patients with COPD.
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Affiliation(s)
- Nicola A Hanania
- a Section of Pulmonary and Critical Care Medicine , Baylor College of Medicine , Houston , TX , USA
| | - Suzanne C Lareau
- b College of Nursing , University of Colorado Denver , Aurora , CO , USA
| | - Barbara P Yawn
- c Department of Family and Community Health , University of Minnesota , Minneapolis , MN , USA
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169
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Halpin DM, Kaplan AG, Russell RK. Why choose tiotropium for my patient? A comprehensive review of actions and outcomes versus other bronchodilators. Respir Med 2017; 128:28-41. [PMID: 28610667 DOI: 10.1016/j.rmed.2017.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) and asthma are leading causes of morbidity and mortality. This narrative review provides an appraisal of the pharmacological and clinical characteristics of tiotropium in COPD and asthma, and examines how these compare with other long-acting bronchodilators. The evidence base is placed into context by relating it to factors affecting clinicians' choice of therapy. MAIN FINDINGS Desirable attributes of a long-acting muscarinic antagonist (LAMA) maintenance therapy include effective pharmacological bronchodilation, improved lung function, exacerbation efficacy, and positive effects on symptom control, exercise capacity and quality of life across a broad patient population. Tolerability and convenience of use are also important for patient well-being and treatment adherence. Tiotropium shows higher affinity for muscarinic receptors than ipratropium, and prolonged binding to the M3 receptor compared with other LAMAs. In COPD, tiotropium has demonstrated improved lung function and exacerbation prevention compared with placebo or long-acting β2-agonists, similar exacerbation efficacy to other LAMAs, and enhanced symptom control and health status versus placebo. UniTinA-asthma® showed the benefits of add-on tiotropium in patients with uncontrolled mild to moderate and severe asthma. Tiotropium is well tolerated, with an incidence of adverse events similar to placebo, except for known infrequent side effects of anticholinergics. Tiotropium HandiHaler® and Respimat® augment inhaler choice in COPD. PRINCIPAL CONCLUSIONS With over 10 years' prescribing history and 50 million patient-years of use, tiotropium has the benefit of a more extensive clinical evidence base than other long-acting bronchodilators, with demonstrated efficacy and safety in COPD and symptomatic asthma.
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Affiliation(s)
- David M Halpin
- Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, United Kingdom.
| | - Alan G Kaplan
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, ON M5G 1V7, Canada.
| | - Richard K Russell
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DS, United Kingdom.
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170
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Zykov KA, Ovcharenko SI. Approaches to drug therapy for COPD in Russia: a proposed therapeutic algorithm. Int J Chron Obstruct Pulmon Dis 2017; 12:1125-1133. [PMID: 28442899 PMCID: PMC5396832 DOI: 10.2147/copd.s125594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Until recently, there have been few clinical algorithms for the management of patients with COPD. Current evidence-based clinical management guidelines can appear to be complex, and they lack clear step-by-step instructions. For these reasons, we chose to create a simple and practical clinical algorithm for the management of patients with COPD, which would be applicable to real-world clinical practice, and which was based on clinical symptoms and spirometric parameters that would take into account the pathophysiological heterogeneity of COPD. This optimized algorithm has two main fields, one for nonspecialist treatment by primary care and general physicians and the other for treatment by specialized pulmonologists. Patients with COPD are treated with long-acting bronchodilators and short-acting drugs on a demand basis. If the forced expiratory volume in one second (FEV1) is ≥50% of predicted and symptoms are mild, treatment with a single long-acting muscarinic antagonist or long-acting beta-agonist is proposed. When FEV1 is <50% of predicted and/or the COPD assessment test score is ≥10, the use of combined bronchodilators is advised. If there is no response to treatment after three months, referral to a pulmonary specialist is recommended for pathophysiological endotyping: 1) eosinophilic endotype with peripheral blood or sputum eosinophilia >3%; 2) neutrophilic endotype with peripheral blood neutrophilia >60% or green sputum; or 3) pauci-granulocytic endotype. It is hoped that this simple, optimized, step-by-step algorithm will help to individualize the treatment of COPD in real-world clinical practice. This algorithm has yet to be evaluated prospectively or by comparison with other COPD management algorithms, including its effects on patient treatment outcomes. However, it is hoped that this algorithm may be useful in daily clinical practice for physicians treating patients with COPD in Russia.
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Affiliation(s)
- Kirill A Zykov
- Laboratory of Pulmonology, Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
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171
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Gulati S, Wells JM. Bringing Stability to the Chronic Obstructive Pulmonary Disease Patient: Clinical and Pharmacological Considerations for Frequent Exacerbators. Drugs 2017; 77:651-670. [PMID: 28255962 PMCID: PMC5396463 DOI: 10.1007/s40265-017-0713-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are critical events associated with an accelerated loss of lung function, increased morbidity, and excess mortality. AECOPD are heterogeneous in nature and this may directly impact clinical decision making, specifically in patients with frequent exacerbations. A 'frequent exacerbator' is a sub-phenotype of chronic obstructive pulmonary disease (COPD) and is defined as an individual who experiences two or more moderate-to-severe exacerbations per year. This distinct subgroup has higher mortality and accounts for more than half of COPD-related hospitalizations annually. Thus, it is imperative to identify individuals at risk for frequent exacerbations and choose optimal strategies to minimize risk for these events. New paradigms for using combination inhalers and the introduction of novel oral compounds provide expanded treatment options to reduce the risk and frequency of exacerbations. The goals of managing frequent exacerbators or patients at risk for AECOPD are: (1) maximizing bronchodilation; (2) reducing inflammation; and (3) targeting specific molecular pathways implicated in COPD and AECOPD pathogenesis. Novel inhaler therapies including combination long-acting muscarinic agents plus long-acting beta agonists show promising results compared with monotherapy or a long-acting beta agonist inhaled corticosteroid combination in reducing exacerbation risk among individuals at risk for exacerbations and among frequent exacerbators. Likewise, oral medications including macrolides and phosphodiesterase-4 inhibitors reduce the risk for AECOPD in select groups of individuals at high risk for exacerbation. Future direction in COPD management is based on the identification of various subtypes or 'endotypes' and targeting therapies based on their pathophysiology. This review describes the impact of AECOPD and the challenges posed by frequent exacerbators, and explores the rationale for different pharmacologic approaches to preventing AECOPD in these individuals.
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Affiliation(s)
- Swati Gulati
- Division of Pulmonary, Allergy and Critical Care, Lung Health Center, University of Alabama Birmingham, Birmingham, AL, USA
| | - J Michael Wells
- Division of Pulmonary, Allergy and Critical Care, Lung Health Center, University of Alabama Birmingham, Birmingham, AL, USA.
- Birmingham VA Medical Center, Birmingham, AL, USA.
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172
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O'Donnell DE, Casaburi R, Frith P, Kirsten A, De Sousa D, Hamilton A, Xue W, Maltais F. Effects of combined tiotropium/olodaterol on inspiratory capacity and exercise endurance in COPD. Eur Respir J 2017; 49:1601348. [PMID: 28424359 PMCID: PMC5898947 DOI: 10.1183/13993003.01348-2016] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 12/14/2016] [Indexed: 11/05/2022]
Abstract
Two replicate, double-blind, 6-week, incomplete-crossover studies (MORACTO 1 and 2) assessed the effects of tiotropium/olodaterol on inspiratory capacity and exercise endurance time in patients with moderate to severe chronic obstructive pulmonary disease.For each patient, four of five treatments were administered once daily for 6 weeks, with a 21-day washout between treatments: tiotropium/olodaterol 2.5/5 µg or 5/5 µg, tiotropium 5 µg, olodaterol 5 µg or placebo, all via the Respimat inhaler. Primary outcomes were inspiratory capacity prior to exercise and exercise endurance time during constant work-rate cycle ergometry to symptom limitation at 75% of peak incremental work rate after 6 weeks (2 h post-dose).295 and 291 patients were treated in MORACTO 1 and 2, respectively. Tiotropium/olodaterol 2.5/5 and 5/5 µg provided significant improvements in inspiratory capacity versus placebo and monotherapies (p<0.0001), and significant improvements in exercise endurance time versus placebo (p<0.0001). Intensity of breathing discomfort was reduced following both doses of tiotropium/olodaterol versus placebo (p<0.0001).Once-daily tiotropium/olodaterol yielded improvements in lung hyperinflation versus placebo and statistically significant improvements versus monotherapies. Tiotropium/olodaterol also showed improvements in dyspnoea and exercise tolerance versus placebo but not consistently versus monotherapies.
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Affiliation(s)
- Denis E O'Donnell
- Division of Respiratory and Critical Care Medicine, Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - Richard Casaburi
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Peter Frith
- Respiratory Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Anne Kirsten
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Member of the German Center for Lung Research, Grosshansdorf, Germany
| | | | | | - Wenqiong Xue
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - François Maltais
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
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173
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Rodrigo GJ, Price D, Anzueto A, Singh D, Altman P, Bader G, Patalano F, Fogel R, Kostikas K. LABA/LAMA combinations versus LAMA monotherapy or LABA/ICS in COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2017; 12:907-922. [PMID: 28360514 PMCID: PMC5364009 DOI: 10.2147/copd.s130482] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Randomized controlled trials (RCTs) indicate that long-acting bronchodilator combinations, such as β2-agonist (LABA)/muscarinic antagonist (LAMA), have favorable efficacy compared with commonly used COPD treatments. The objective of this analysis was to compare the efficacy and safety of LABA/LAMA with LAMA or LABA/inhaled corticosteroid (ICS) in adults with stable moderate-to-very-severe COPD. Methods This systematic review and meta-analysis (PubMed/MEDLINE, Embase, Cochrane Library and clinical trial/manufacturer databases) included RCTs comparing ≥12 weeks’ LABA/LAMA treatment with LAMA and/or LABA/ICS (approved doses only). Eligible studies were independently selected by two authors using predefined data fields; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Results Eighteen studies (23 trials) were eligible (N=20,185). LABA/LAMA significantly improved trough forced expiratory volume in 1 second (FEV1) from baseline to week 12 versus both LAMA and LABA/ICS (0.07 L and 0.08 L, P<0.0001), with patients more likely to achieve clinically important improvements in FEV1 of >100 mL (risk ratio [RR]: 1.33, 95% confidence interval [CI]: [1.20, 1.46] and RR: 1.44, 95% CI: [1.33, 1.56], respectively, the number needed to treat being eight and six, respectively). LABA/LAMA improved transitional dyspnea index and St George’s Respiratory Questionnaire scores at week 12 versus LAMA (both P<0.0001), but not versus LABA/ICS, and reduced rescue medication use versus both (P<0.0001 and P=0.001, respectively). LABA/LAMA significantly reduced moderate/severe exacerbation rate compared with LABA/ICS (RR 0.82, 95% CI: [0.75, 0.91]). Adverse event (AE) incidence was no different for LABA/LAMA versus LAMA treatment, but it was lower versus LABA/ICS (RR 0.94, 95% CI: [0.89, 0.99]), including a lower pneumonia risk (RR 0.59, 95% CI: [0.43, 0.81]). LABA/LAMA presented a lower risk for withdrawals due to lack of efficacy versus LAMA (RR: 0.66, 95% CI: [0.51, 0.87]) and due to AEs versus LABA/ICS (RR: 0.83, 95% CI: [0.69, 0.99]). Conclusion The greater efficacy and comparable safety profiles observed with LABA/LAMA combinations versus LAMA or LABA/ICS support their potential role as first-line treatment options in COPD. These findings are of direct relevance to clinical practice because we included all currently available LABA/LAMAs and comparators, only at doses approved for clinical use.
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Affiliation(s)
- Gustavo J Rodrigo
- Departamento de Emergencia, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - David Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK; Observational and Pragmatic Research Institute, Singapore
| | - Antonio Anzueto
- University of Texas Health Science Center; South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Dave Singh
- Medicines Evaluation Unit, National Institute for Health Research Respiratory and Allergy Clinical Research Facility, University Hospital of South Manchester NHS Foundation Trust, University of Manchester, Manchester, England, UK
| | - Pablo Altman
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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174
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D'Urzo A, Singh D, Garcia Gil E. Use of concomitant inhaled corticosteroids: pooled data from two phase III studies of aclidinium plus formoterol in COPD. NPJ Prim Care Respir Med 2017; 27:13. [PMID: 28235977 PMCID: PMC5434772 DOI: 10.1038/s41533-016-0009-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 11/28/2016] [Accepted: 12/02/2016] [Indexed: 11/08/2022] Open
Abstract
Bronchodilator therapy is the backbone of the management of chronic obstructive pulmonary disease. In some patients, inhaled corticosteroids can be prescribed in combination with bronchodilators. Through a subgroup analysis of pooled data from two large phase III clinical trials of bronchodilator therapy according to concomitant inhaled corticosteroid use (user vs. non-user), we sought to evaluate the clinical benefit of adding inhaled corticosteroids to dual bronchodilator therapy in chronic obstructive pulmonary disease. The primary focus of this analysis of pooled data from the phase III ACLIFORM and AUGMENT studies was to evaluate the efficacy of aclidinium/formoterol on lung function stratified by inhaled corticosteroid use. We found that lung-function end points were significantly improved regardless of concomitant inhaled corticosteroid use among patients treated with the dual bronchodilator aclidinium/formoterol 400/12 µg twice daily compared with placebo and both monotherapies. Together with the previously reported observations that aclidinium/formoterol 400/12 µg reduces exacerbations vs. placebo in inhaled corticosteroid users and improves dyspnoea compared to monotherapy in inhaled corticosteroid non-users, these data suggest that both groups achieve lung function improvements, which translates to different clinical benefits depending on whether or not a patient is receiving concomitant inhaled corticosteroids.CHRONIC LUNG DISEASE: 'TRIPLE' THERAPY COULD PROVE BENEFICIAL: A dual bronchodilator therapy taken together with corticosteroid inhalers may benefit patients with severe chronic lung disease. Bronchodilator drugs relax the lungs and widen airways in patients with chronic obstructive pulmonary disease (COPD). While recent studies have shown that a dual bronchodilator therapy containing aclidinium and formoterol significantly improves lung function in COPD, little is known about combining the dual therapy with inhaled corticosteroids (ICSs). Anthony D'Urzo at the University of Toronto, Canada, and co-workers analysed data from 3394 patients with COPD undergoing dual therapy trials. Of these, 1180 were already taking ICSs. The team compared symptoms in the ICS group with those not taking ICSs. The dual therapy improved lung function across both groups regardless of ICS use, though patients gained different clinical benefits depending on ICS use and disease severity.
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Affiliation(s)
- Anthony D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Dave Singh
- The University of Manchester, Medicines Evaluation Unit, University Hospital of South Manchester Foundation Trust, Centre for Respiratory and Allergy Medicine, Manchester, UK
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175
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Miravitlles M, Anzueto A. A new two-step algorithm for the treatment of COPD. Eur Respir J 2017; 49:49/2/1602200. [DOI: 10.1183/13993003.02200-2016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/20/2016] [Indexed: 11/05/2022]
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176
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Effect of tiotropium and olodaterol on symptoms and patient-reported outcomes in patients with COPD: results from four randomised, double-blind studies. NPJ Prim Care Respir Med 2017; 27:7. [PMID: 28154373 PMCID: PMC5434778 DOI: 10.1038/s41533-016-0002-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 10/21/2016] [Accepted: 11/01/2016] [Indexed: 11/29/2022] Open
Abstract
Chronic obstructive pulmonary disease is associated with significant morbidity and mortality. Trials of maintenance chronic obstructive pulmonary disease treatments focus on improvement in lung function and reductions in exacerbations, while patients are much more concerned about symptoms and health status. Our aim was to investigate the effects of tiotropium + olodaterol on patient-reported health outcomes, breathlessness and night-time rescue medication use in patients with chronic obstructive pulmonary disease, compared to placebo, tiotropium or olodaterol monotherapy. Two pairs of replicate, phase III studies of 12 (OTEMTO 1 + 2) and 52 weeks’ (TONADO 1 + 2) duration were evaluated, in which patients received either tiotropium + olodaterol 2.5/5 or 5/5 μg, tiotropium 2.5 or 5 μg, olodaterol 5 μg or placebo, all delivered once daily via Respimat inhaler. Patient-reported outcomes included breathlessness assessed by transition dyspnoea index focal score, health status assessed by St George’s Respiratory Questionnaire total score and night-time rescue medication use at 12 or 24 weeks. Outcomes from the pooled study data are reported. Overall, 1621 and 5162 patients were treated in the OTEMTO and TONADO trials, respectively. Significantly larger improvements in St George’s Respiratory Questionnaire and transition dyspnoea index focal scores were observed and a greater proportion of patients were responders to therapy (based on minimum clinically important differences in St George’s Respiratory Questionnaire and transition dyspnoea index) with tiotropium + olodaterol compared to either monotherapy or to placebo. Tiotropium + olodaterol 5/5 µg significantly reduced night-time rescue medication usage. Results from four in-depth studies show that a combined inhaler is very effective for treatment of moderate to severe chronic lung disease. Alleviating the symptoms of chronic obstructive pulmonary disease (COPD), particularly sleep disturbance, is crucial to enhancing patients’ quality of life. Gary Ferguson at the Pulmonary Research Institute of Southeast Michigan, together with other scientists across the USA and Germany, analysed data from four large-scale studies to evaluate the efficacy of STIOLTO Respimat, a combination of two bronchodilators—tiotropium, and olodaterol, which tackle airway obstruction and breathlessness, improving long-term lung function. They found that the new drug combination triggered significant improvements in patients’ quality of life and levels of breathlessness. Use of night-time rescue medication in patients on STIOLTO Respimat was considerably reduced. A greater number of patients responded positively to the combined inhaler than to monotherapy.
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177
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Singh D, Miravitlles M, Vogelmeier C. Chronic Obstructive Pulmonary Disease Individualized Therapy: Tailored Approach to Symptom Management. Adv Ther 2017; 34:281-299. [PMID: 27981495 PMCID: PMC5331083 DOI: 10.1007/s12325-016-0459-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 02/06/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with high morbidity and mortality. COPD is typified by persistent, progressive airflow limitation and a range of respiratory and systemic symptoms such as breathlessness, coughing, wheezing, depression, anxiety, general fatigue, and sleeping difficulties. Despite receiving treatment for COPD, many patients suffer from regular symptoms that affect their daily lives and lead to increased morbidity. These symptoms vary in severity, frequency, and type, and can occur at any time throughout the 24-h day, with over half of patients with COPD experiencing symptoms in the morning, during the day, and at nighttime. Despite the prevalence of symptoms, patient and physician perception of the impact of COPD symptoms on patients' lives is not always in concordance. Dual bronchodilator therapy with a long-acting muscarinic antagonist (LAMA) and long-acting beta agonist (LABA) has the potential to treat the symptoms of COPD in addition to improving lung function. This review therefore examines the burden of symptoms experienced throughout the day by patients with COPD and the evidence for combined LAMA/LABA treatment in terms of symptom management. As patients with COPD experience varying symptoms throughout the course of their disease, the role of tailoring treatment to the individual needs of the patient is also examined. We conclude that the symptoms of COPD are troublesome, variable, can occur during all parts of the 24-h day, and have a substantial impact on patients' health status and quality of life. In order to provide effective, patient-orientated care, patients with COPD should be evaluated on the basis of lung function, the frequency of symptoms, and patient-perceived impact of symptoms on their lives. Therapy should be chosen carefully based on individualized assessment, ensuring personalization to the individual needs of the patient.
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Affiliation(s)
- Dave Singh
- University of Manchester, Manchester, UK.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Claus Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL), University Medical Center Giessen and Marburg, Philipps-University Marburg, Marburg, Germany
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178
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Martinez FJ, Rabe KF, Ferguson GT, Fabbri LM, Rennard S, Feldman GJ, Sethi S, Spangenthal S, Gottschlich GM, Rodriguez-Roisin R, Arora S, Siler TM, Siddiqui S, Darken P, Fischer T, Maes A, Golden M, Orevillo C, Reisner C. Efficacy and Safety of Glycopyrrolate/Formoterol Metered Dose Inhaler Formulated Using Co-Suspension Delivery Technology in Patients With COPD. Chest 2017; 151:340-357. [DOI: 10.1016/j.chest.2016.11.028] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/04/2016] [Accepted: 11/02/2016] [Indexed: 11/25/2022] Open
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179
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Calzetta L, Rogliani P, Ora J, Puxeddu E, Cazzola M, Matera MG. LABA/LAMA combination in COPD: a meta-analysis on the duration of treatment. Eur Respir Rev 2017; 26:26/143/160043. [DOI: 10.1183/16000617.0043-2016] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/24/2016] [Indexed: 01/10/2023] Open
Abstract
When there are no randomised clinical trials directly comparing all relevant treatment options, an indirect treatment comparison via meta-analysis of the available clinical evidence is an acceptable alternative. However, meta-analyses may be very misleading if not adequately performed. Here, we propose and validate a simple and effective approach to meta-analysis for exploring the effectiveness of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combinations in chronic obstructive pulmonary disease.14 articles with 20 329 patients (combinations n=9292; monocomponents n=11 037) were included in this study. LABA/LAMA combinations were always more effective than the monocomponents in terms of the improvement in trough forced expiratory volume in 1 s, transition dyspnoea index and St George's Respiratory Questionnaire scores after 3, 6 and 12 months of treatment. No significant publication bias was identified. Significant discrepancies with previous network meta-analyses have been found, with overall differences ranging from 26.7% to 43.3%.Results from previous network meta-analyses were misleading because no adequate attention was given to formulating the review question, specifying eligibility criteria, correctly identifying studies, collecting appropriate information and deciding what it would be pharmacologically relevant to analyse. The real gradient of effectiveness of LABA/LAMA fixed-dose combinations remains an unmet medical need; however, it can be investigated indirectly using a high-quality meta-analytic approach.
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180
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Reisner C, Fabbri LM, Kerwin EM, Fogarty C, Spangenthal S, Rabe KF, Ferguson GT, Martinez FJ, Donohue JF, Darken P, St Rose E, Orevillo C, Strom S, Fischer T, Golden M, Dwivedi S. A randomized, seven-day study to assess the efficacy and safety of a glycopyrrolate/formoterol fumarate fixed-dose combination metered dose inhaler using novel Co-Suspension™ Delivery Technology in patients with moderate-to-very severe chronic obstructive pulmonary disease. Respir Res 2017; 18:8. [PMID: 28061907 PMCID: PMC5216561 DOI: 10.1186/s12931-016-0491-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-acting muscarinic antagonist/long-acting β2-agonist combinations are recommended for patients whose chronic obstructive pulmonary disease (COPD) is not managed with monotherapy. We assessed the efficacy and safety of glycopyrrolate (GP)/formoterol fumarate (FF) fixed-dose combination delivered via a Co-Suspension™ Delivery Technology-based metered dose inhaler (MDI) (GFF MDI). METHODS This was a Phase IIb randomized, multicenter, placebo-controlled, double-blind, chronic-dosing (7 days), crossover study in patients with moderate-to-very severe COPD ( NCT01085045 ). Treatments included GFF MDI twice daily (BID) (GP/FF 72/9.6 μg or 36/9.6 μg), GP MDI 36 μg BID, FF MDI 7.2 and 9.6 μg BID, placebo MDI, and open-label formoterol dry powder inhaler (FF DPI) 12 μg BID or tiotropium DPI 18 μg once daily. The primary endpoint was forced expiratory volume in 1 s area under the curve from 0 to 12 h (FEV1 AUC0-12) on Day 7 relative to baseline FEV1. Secondary endpoints included pharmacokinetics and safety. RESULTS GFF MDI 72/9.6 μg or 36/9.6 μg led to statistically significant improvements in FEV1 AUC0-12 after 7 days' treatment versus monocomponent MDIs, placebo MDI, tiotropium, or FF DPI (p ≤ 0.0002). GFF MDI 36/9.6 μg was non-inferior to GFF MDI 72/9.6 μg and monocomponent MDIs were non-inferior to open-label comparators. Pharmacokinetic results showed glycopyrrolate and formoterol exposure were decreased following administration via fixed-dose combination versus monocomponent MDIs; however, this was not clinically meaningful. GFF MDI was well tolerated. CONCLUSIONS GFF MDI 72/9.6 μg and 36/9.6 μg BID improve lung function and are well tolerated in patients with moderate-to-very severe COPD. TRIAL REGISTRATION ClinicalTrials.gov NCT01085045 . Registered 9 March 2010.
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Affiliation(s)
- Colin Reisner
- Pearl Therapeutics Inc., 280 Headquarters Plaza, East Tower, 2nd Floor, Morristown, NJ, 07960, USA.
| | - Leonardo M Fabbri
- Department of Medicine, University of Modena and Reggio Emilia, NOCSAE, Modena, Italy
| | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | | | - Klaus F Rabe
- Lungen Clinic Grosshansdorf, Airway Research Center North, Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany.,Department of Medicine, Christian-Albrechts University Kiel, Kiel, MI, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Fernando J Martinez
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College; New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - James F Donohue
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Patrick Darken
- Pearl Therapeutics Inc., 280 Headquarters Plaza, East Tower, 2nd Floor, Morristown, NJ, 07960, USA
| | - Earl St Rose
- Pearl Therapeutics Inc., 280 Headquarters Plaza, East Tower, 2nd Floor, Morristown, NJ, 07960, USA
| | - Chad Orevillo
- Pearl Therapeutics Inc., 280 Headquarters Plaza, East Tower, 2nd Floor, Morristown, NJ, 07960, USA
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181
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Price D, Østrem A, Thomas M, Welte T. Dual bronchodilation in COPD: lung function and patient-reported outcomes - a review. Int J Chron Obstruct Pulmon Dis 2016; 12:141-168. [PMID: 28115839 PMCID: PMC5221557 DOI: 10.2147/copd.s116719] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Several fixed-dose combinations (FDCs) of long-acting bronchodilators (a long-acting muscarinic antagonist [LAMA] plus a long-acting β2-agonist [LABA]) are available for the treatment of COPD. Studies of these FDCs have demonstrated substantial improvements in lung function (forced expiratory volume in 1 second) in comparison with their respective constituent monocomponents. Improvements in patient-reported outcomes (PROs), such as symptoms and health status, as well as exacerbation rates, have been reported compared with a LABA or LAMA alone, but results are less consistent. The inconsistencies may in part be owing to differences in study design, methods used to assess study end points, and patient populations. Nevertheless, these observations tend to support an association between improvements in forced expiratory volume in 1 second and improvements in symptom-based outcomes. In order to assess the effects of FDCs on PROs and evaluate relationships between PROs and changes in lung function, we performed a systematic literature search of publications reporting randomized controlled trials of FDCs. Results of this literature search were independently assessed by two reviewers, with a third reviewer resolving any conflicting results. In total, 22 Phase III randomized controlled trials of FDC bronchodilators in COPD were identified, with an additional study including a post-literature search (ten for indacaterol-glycopyrronium once daily, eight for umeclidinium-vilanterol once daily, three for tiotropium-olodaterol once daily, and two for aclidinium-formoterol twice daily). Results from these studies demonstrated that the LAMA-LABA FDCs significantly improved lung function compared with their component monotherapies or other single-agent treatments. Furthermore, LABA-LAMA combinations also generally improved symptoms and health status versus monotherapies, although some discrepancies between lung function and PROs were observed. Overall, the safety profiles of the FDCs were similar to placebo. Further research is required to examine more closely any relationship between lung function and PROs in patients receiving LABA-LAMA combinations.
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Affiliation(s)
- David Price
- Department of Primary Care Respiratory Medicine, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore
| | | | - Mike Thomas
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - Tobias Welte
- Department of Pulmonary Medicine, Hannover Medical School, Hannover, Germany
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182
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Ichinose M, Kato M, Takizawa A, Sakamoto W, Grönke L, Tetzlaff K, Fukuchi Y. Long-term safety and efficacy of combined tiotropium and olodaterol in Japanese patients with chronic obstructive pulmonary disease. Respir Investig 2016; 55:121-129. [PMID: 28274527 DOI: 10.1016/j.resinv.2016.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/23/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The efficacy and safety of once-daily tiotropium+olodaterol (T+O) (2.5/5µg or 5/5µg) for treating chronic obstructive pulmonary disease (COPD) have been demonstrated in the large, multinational, randomized, Phase III studies TONADO® 1 and 2, which included 413 Japanese patients (~80 in each group). This study was conducted to supplement the TONADO® study data to assess long-term safety in ≥100 Japanese patients treated for 1 year in compliance with International Conference on Harmonisation guidelines. Efficacy was evaluated descriptively as a secondary end point. METHODS Patients were randomized to 52 weeks of double-blind treatment with once-daily T+O (2.5/5 or 5/5µg) or O (5µg) monotherapy via the Respimat® inhaler. We report the safety and efficacy data descriptively. RESULTS The incidence of adverse events (AEs) was comparable in the T+O 2.5/5µg (75.0%), T+O 5/5µg (85.4%), and O 5µg (80.5%) groups, with drug-related AEs being reported in 5.0%, 7.3%, and 4.9% of patients, respectively. Serious AEs were reported in 14 patients (11.5%). The change from baseline in forced expiratory volume in 1s (FEV1) area under the curve from 0 to 3h and trough FEV1 were numerically higher in the T+O treatment groups than in the O monotherapy group throughout the study period. Overall safety of T+O was comparable to that in the TONADO® studies. CONCLUSIONS No safety concerns for long-term T+O treatment were identified in Japanese patients with COPD. A numerical improvement in lung function was observed with T+O treatment compared to O monotherapy.
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Affiliation(s)
- Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
| | - Motokazu Kato
- Kishiwada City Hospital, 1001 Gakuhara-cho, Kishiwada, Osaka 596-8501, Japan.
| | - Ayako Takizawa
- Nippon Boehringer Ingelheim Co. Ltd, 2-1-1 Osaki, Shinagawa-ku, Tokyo 141-6017, Japan.
| | - Wataru Sakamoto
- Nippon Boehringer Ingelheim Co. Ltd, 2-1-1 Osaki, Shinagawa-ku, Tokyo 141-6017, Japan.
| | - Lars Grönke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216 Ingelheim am Rhein, Germany.
| | - Kay Tetzlaff
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216 Ingelheim am Rhein, Germany; Department of Sports Medicine, University of Tübingen, Hoppe-Seyler-Strasse 6, 72076 Tübingen, Germany.
| | - Yoshinosuke Fukuchi
- Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
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183
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Derom E, Brusselle GG, Joos GF. Efficacy of tiotropium-olodaterol fixed-dose combination in COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:3163-3177. [PMID: 28008243 PMCID: PMC5167492 DOI: 10.2147/copd.s92840] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Tiotropium-olodaterol, formulated in the Respimat soft-mist inhaler, is an inhaled fixed-dose combination (FDC) of a long-acting muscarinic antagonist (LAMA) and a long-acting β2-agonist (LABA), commercialized under the name of Spiolto or Stiolto. The efficacy of tiotropium-olodaterol 5-5 μg once daily in adult patients with COPD was documented in eleven large, multicenter trials of up to 52 weeks duration. Tiotropium-olodaterol 5-5 μg not only improved spirometric values to a significantly greater extent than placebo but also resulted in statistically significant beneficial effects on dyspnea, markers of hyperinflation, use of rescue medication, health-related quality of life, and exercise endurance. Improvements exceeded the minimal clinically important difference (MCID) for forced expiratory volume in 1 second (FEV1), dyspnea, and quality of life. Differences between tiotropium-olodaterol 5-5 μg and the respective monocomponents were statistically significant for FEV1, dyspnea, markers of hyperinflation, use of rescue medication, and health-related quality of life, but did not reach the MCID. However, dual bronchodilatation significantly increased the number of patients who exceeded the MCID for dyspnea and quality of life. Moreover, tiotropium-olodaterol 5-5 μg was significantly more effective than salmeterol-fluticasone (FDC) twice daily at improving pulmonary function. Differences between tiotropium-olodaterol and other LAMA/LABA FDCs were not observed for FEV1 or other efficacy markers. Therefore, tiotropium-olodaterol is a valuable option in the treatment of COPD patients who remain symptomatic under monotherapy.
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Affiliation(s)
- Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Guy F Joos
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
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184
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Kardos P, Worsley S, Singh D, Román-Rodríguez M, Newby DE, Müllerová H. Randomized controlled trials and real-world observational studies in evaluating cardiovascular safety of inhaled bronchodilator therapy in COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:2885-2895. [PMID: 27932872 PMCID: PMC5135074 DOI: 10.2147/copd.s118867] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Long-acting muscarinic antagonist (LAMA) or long-acting β2-agonist (LABA) bronchodilators and their combination are recommended for the maintenance treatment of chronic obstructive pulmonary disease (COPD). Although the efficacy of LAMAs and LABAs has been well established through randomized controlled trials (RCTs), questions remain regarding their cardiovascular (CV) safety. Furthermore, while the safety of LAMA and LABA monotherapy has been extensively studied, data are lacking for LAMA/LABA combination therapy, and the majority of the studies that have reported on the CV safety of LAMA/LABA combination therapy were not specifically designed to assess this. Evaluation of CV safety for COPD treatments is important because many patients with COPD have underlying CV comorbidities. However, severe CV and other comorbidities are often exclusion criteria for RCTs, contributing to a lack in external validity and generalizability. Real-world observational studies are another important tool to evaluate the effectiveness and safety of COPD therapies in a broader population of patients and can improve upon the external validity limitations of RCTs. We examine what is already known regarding the CV and cerebrovascular safety of LAMA/LABA combination therapy from RCTs and real-world observational studies, and explore the advantages and limitations of data derived from each study type. We also describe an ongoing prospective, observational, comparative post-authorization safety study of a LAMA/LABA combination therapy (umeclidinium/vilanterol) and LAMA monotherapy (umeclidinium) versus tiotropium, with a focus on the relative merits of the study design.
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Affiliation(s)
- Peter Kardos
- Group Practice and Respiratory, Allergy and Sleep Unit, Red Cross Maingau Hospital, Frankfurt, Germany
| | | | - Dave Singh
- University of Manchester, Medicines Evaluation Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Miguel Román-Rodríguez
- Primary Care Respiratory Research Unit, Instituto de Investigación Sanitaria de Palma IdisPa, Palma de Mallorca, Spain
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
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185
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Zysman M, Chabot F, Devillier P, Housset B, Morelot-Panzini C, Roche N. Pharmacological treatment optimization for stable chronic obstructive pulmonary disease. Proposals from the Société de Pneumologie de Langue Française. Rev Mal Respir 2016; 33:911-936. [PMID: 27890625 DOI: 10.1016/j.rmr.2016.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/23/2016] [Indexed: 10/20/2022]
Abstract
The Société de Pneumologie de Langue Française proposes a decision algorithm on long-term pharmacological COPD treatment. A working group reviewed the literature published between January 2009 and May 2016. This document lays out proposals and not guidelines. It only focuses on pharmacological treatments except vaccinations, smoking cessation treatments and oxygen therapy. Any COPD diagnosis, based on pulmonary function tests, should lead to recommend smoking cessation, vaccinations, physical activity, pulmonary rehabilitation in case of activity limitation, and short-acting bronchodilators. Symptoms like dyspnea and exacerbations determine the therapeutic choices. In case of daily dyspnea and/or exacerbations, a long-acting bronchodilator should be suggested (beta-2 agonist, LABA or anticholinergics, LAMA). A clinical and lung function reevaluation is suggested 1 to 3 months after any treatment modification and every 3-12 months according to the severity of the disease. In case of persisting dyspnea, a fixed dose LABA+LAMA combination improves pulmonary function (FEV1), quality of life, dyspnea and decreases exacerbations without increasing side effects. In case of frequent exacerbations and a FEV1≤70%, a fixed dose long-acting bronchodilator combination or a LABA+ inhaled corticosteroids (ICS) combination can be proposed. A triple combination (LABA+LAMA+ICS) is indicated when exacerbations persist despite one of these combinations. Dyspnea in spite of a bronchodilator combination or exacerbations in spite of a triple combination should lead to consider other pharmacological treatments (theophylline if dyspnea, macrolides if exacerbations, low-dose opioids if refractory dyspnea).
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Affiliation(s)
- M Zysman
- EA Ingres, département de pneumologie, université de Lorraine, CHU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - F Chabot
- EA Ingres, département de pneumologie, université de Lorraine, CHU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - P Devillier
- UPRES EA 220, département des maladies des voies respiratoires, hôpital Foch, université Versailles-Saint-Quentin, 92150 Suresnes, France
| | - B Housset
- Service de pneumologie, UPEC, université Paris-Est, UMR S955, centre hospitalier intercommunal de Créteil, 94000 Créteil, France
| | - C Morelot-Panzini
- Service de pneumologie et réanimation médicale, groupe hospitalier Pitié-Salpêtrière Charles-Foix, Inserm, université Pierre-et-Marie-Curie, UMRS 1158, 75013 Paris, France
| | - N Roche
- Service de pneumologie, hôpital Cochin, AP-HP, EA2511, université Paris Descartes, Sorbonne Paris Cité, 75014 Paris, France.
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186
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Buhl R, Magder S, Bothner U, Tetzlaff K, Voß F, Loaiza L, Vogelmeier CF, McGarvey L. Long-term general and cardiovascular safety of tiotropium/olodaterol in patients with moderate to very severe chronic obstructive pulmonary disease. Respir Med 2016; 122:58-66. [PMID: 27993292 DOI: 10.1016/j.rmed.2016.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/31/2016] [Accepted: 11/13/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term safety, particularly cardiovascular safety, is of special interest in maintenance treatment of chronic obstructive pulmonary disease (COPD) with long-acting β2-agonists and long-acting muscarinic antagonists, given potential cardiovascular effects. METHODS Two 52-week Phase III trials (TONADO®) investigated tiotropium/olodaterol (5/5 and 2.5/5 μg) versus tiotropium 2.5, 5 μg and olodaterol 5 μg. In a pre-specified safety analysis, investigator-reported treatment-emergent adverse events (AEs), electrocardiogram and laboratory data were pooled. All serious AE (SAE) reports were reviewed by an independent Adjudication Committee, which assessed whether deaths, hospitalisations or intubations were respiratory, cardiovascular, cerebrovascular or other disease related. Subgroup analyses investigated cardiovascular safety including major cardiac events in patients with cardiovascular co-morbidities. RESULTS This analysis comprised 3100 patients with moderate to very severe COPD, treated for ≤1 year, including 784 patients with cardiovascular co-morbidities. AEs were balanced across treatments in the total population as well as in patient subgroups with pre-existing cardiovascular co-morbidities. The incidence and nature of events were consistent with the disease under study and a 1-year trial duration. 494/3100 patients contributed to an adjudicated analysis of SAEs: 260 had respiratory-related, 53 had cardiovascular-related and 16 had cerebrovascular-related SAEs. Incidences of these SAEs were comparable between treatments. There was no evidence of any increased risk for the combination compared to the monotherapy groups. CONCLUSIONS These data provide confidence for clinicians that tiotropium/olodaterol 5/5 μg can be safely administered once-daily to patients with moderate to very severe COPD long-term, including those with significant cardiovascular co-morbidity. TRIAL REGISTRY ClinicalTrials.gov, Nos.: NCT01431274, NCT01431287.
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany.
| | | | - Ulrich Bothner
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Kay Tetzlaff
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany; Department of Sports Medicine, Medical Clinic V, University of Tübingen, Tübingen, Germany
| | - Florian Voß
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Lazaro Loaiza
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Lorcan McGarvey
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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187
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Tebboth A, Ternouth A, Gonzalez-Rojas N. UK-specific cost-effectiveness of tiotropium + olodaterol fixed-dose combination versus other LAMA + LABA combinations in patients with COPD. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:667-674. [PMID: 27853383 PMCID: PMC5106216 DOI: 10.2147/ceor.s116546] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study is to assess the cost-effectiveness of other long-acting muscarinic antagonist + long-acting β2 agonist combinations in comparison with Spiolto® Respimat® (tiotropium + olodaterol fixed-dose combination [FDC]) for maintenance treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease. METHODS A previously published individual-level Markov model was adapted for the perspective of the UK health care system, in line with recommendations from the National Institute for Health and Care Excellence. Individuals progressed through the model based on their forced expiratory volume in 1 second (FEV1) value at baseline and the post-improvement FEV1 value. Changes in FEV1 were taken from a mixed treatment comparison. Costs were obtained from a published cost-utility analysis of tiotropium in the treatment of chronic obstructive pulmonary disease in the UK. Uncertainty was assessed by deterministic and probabilistic sensitivity analysis. RESULTS Duaklir® Genuair® (aclidinium bromide + formoterol fumarate FDC) and the free-dose combination of tiotropium + salmeterol were dominated by tiotropium + olodaterol FDC. The quality-adjusted life years and costs were identical for Ultibro® Breezhaler® (indacaterol + glycopyrronium FDC) and Anoro™ Ellipta® (umeclidinium + vilanterol FDC) compared with tiotropium + olodaterol FDC, resulting in identical incremental cost-effectiveness ratios. CONCLUSION This analysis shows tiotropium + olodaterol FDC to be a cost-effective option for the maintenance treatment of adults with chronic obstructive pulmonary disease in the UK.
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Landis SH, Wurst K, Le HV, Bonar K, Punekar YS. Can Assessment of Disease Burden Prior to Changes in Initial COPD Maintenance Treatment Provide Insight into Remaining Unmet Needs? A Retrospective Database Study in UK Primary Care. COPD 2016; 14:80-85. [PMID: 27819513 DOI: 10.1080/15412555.2016.1240159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This retrospective cohort study aimed to assess treatment patterns over 24 months amongst patients with chronic obstructive pulmonary disease (COPD), initiating a new COPD maintenance treatment, and to understand clinical indicators of treatment change. Patients included in the study initiated a long-acting β2-agonist (LABA), a long-acting muscarinic antagonist (LAMA), or a combination of LABA and an inhaled corticosteroid (ICS/LABA) between January 1, 2009, and November 30, 2013, as recorded in the United Kingdom Clinical Practice Research Datalink (UK CPRD). Treatment modifications (switching or adding maintenance treatments) over 24 months were assessed, and patient characteristics, disease burden, medication and healthcare resource use during the 30 days before treatment modification were evaluated. The cohort comprised 17,258 patients [LABA (8%), LAMA (39%) and ICS/LABA (54%)] with similar age, body mass index and dyspnoea distribution. LABA users were more likely than LAMA users to add a maintenance therapy. Distinct patterns of treatment augmentations were noted, whereby LABA users typically received dual therapy before moving to triple therapy, while LAMA users moved to triple therapy by directly adding an ICS/LABA. Exacerbation events immediately prior to treatment change were not frequently recorded; however, the need for rescue short-acting medication and assessment of dyspnoea in the 30 days prior to the treatment change suggest that dyspnoea is a remaining unmet need driving therapy change.
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Affiliation(s)
- Sarah H Landis
- a Real World Evidence, GlaxoSmithKline R&D , Uxbridge , UK
| | - Keele Wurst
- b Real World Evidence, GlaxoSmithKline R&D , Upper Providence , PA , USA
| | - Hoa Van Le
- c Health Economics & Real World Evidence, Parexel International , Durham , NC , USA.,d GlaxoSmithKline R&D, Research Triangle Park , NC , USA
| | - Kerina Bonar
- a Real World Evidence, GlaxoSmithKline R&D , Uxbridge , UK
| | - Yogesh S Punekar
- e Value Evidence and Outcomes, GlaxoSmithKline R&D , Brentford , UK
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189
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van der Molen T, van Boven JFM, Maguire T, Goyal P, Altman P. Optimizing identification and management of COPD patients - reviewing the role of the community pharmacist. Br J Clin Pharmacol 2016; 83:192-201. [PMID: 27510273 PMCID: PMC5225927 DOI: 10.1111/bcp.13087] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 07/08/2016] [Accepted: 08/01/2016] [Indexed: 01/03/2023] Open
Abstract
The aim of this paper was to propose key steps for community pharmacist integration into a patient care pathway for chronic obstructive pulmonary disease (COPD) management. A literature search was conducted to identify publications focusing on the role of the community pharmacist in identification and management of COPD. The literature search highlighted evidence supporting an important role for pharmacists at each of the four key steps in the patient care pathway for COPD management. Step 1 (primary prevention): pharmacists are ideally placed to provide information on disease awareness and risk prevention campaigns, and to encourage lifestyle interventions, including smoking cessation. Step 2 (early detection/case finding): pharmacists are often the first point of contact between the patient and the healthcare system and can therefore play an important role in the early identification of patients with COPD. Step 3 (management and ongoing support): pharmacists can assist patients by providing advice and education on dosage, inhaler technique, treatment expectations and the importance of adherence, and by supporting self‐management, including recognition and treatment of COPD exacerbations. Step 4 (review and follow‐up): pharmacists can play an important role in monitoring adherence and ongoing inhaler technique in patients with COPD. In summary, pharmacists are ideally positioned to play a vital role in all key stages of an integrated COPD patient care pathway from early disease detection to the support of management plans, including advice and counselling regarding medications, inhaler technique and treatment adherence. Areas requiring additional consideration include pharmacist training, increasing awareness of the pharmacist role, administration and reimbursement, and increasing physician–pharmacist collaboration.
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Affiliation(s)
- Thys van der Molen
- Department of Primary Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Job F M van Boven
- Department of Pharmacy, Unit of PharmacoEpidemiology and PharmacoEconomics, University of Groningen, Groningen, The Netherlands
| | - Terence Maguire
- Community Pharmacist and School of Pharmacy, Queen's University, Belfast, UK
| | | | - Pablo Altman
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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190
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Tashkin DP, Martinez FJ, Rodriguez-Roisin R, Fogarty C, Gotfried M, Denenberg M, Gottschlich G, Donohue JF, Orevillo C, Darken P, St Rose E, Strom S, Fischer T, Golden M, Reisner C. A multicenter, randomized, double-blind dose-ranging study of glycopyrrolate/formoterol fumarate fixed-dose combination metered dose inhaler compared to the monocomponents and open-label tiotropium dry powder inhaler in patients with moderate-to-severe COPD. Respir Med 2016; 120:16-24. [DOI: 10.1016/j.rmed.2016.09.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/14/2016] [Accepted: 09/16/2016] [Indexed: 11/24/2022]
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191
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Ferguson GT, Karpel JP, Clerisme-Beaty E, Grönke L, Voß F, Buhl R. Efficacy and safety of tiotropium + olodaterol maintenance treatment in patients with COPD in the TONADO ® and OTEMTO ® studies: a subgroup analysis by age. Int J Chron Obstruct Pulmon Dis 2016; 11:2701-2710. [PMID: 27843306 PMCID: PMC5098524 DOI: 10.2147/copd.s108758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Increasing age is associated with poor prognosis in patients with COPD. Objective This analysis from the replicate Phase III OTEMTO® and TONADO® studies examined the efficacy and safety of tiotropium, a long-acting anticholinergic, combined with olodaterol, a long-acting β2-agonist, compared to monotherapies and placebo in patients with COPD aged 40 years to <65 years, 65 years to <75 years, 75 years to <85 years, and ≥85 years. Methods In these double-blind, parallel-group, active-controlled, multicenter, randomized studies, patients received tiotropium + olodaterol 2.5/5 μg or 5/5 μg, tiotropium 5 μg or 2.5 μg (TONADO only), olodaterol 5 μg (TONADO only), or placebo (OTEMTO only). This analysis used the approved doses of tiotropium + olodaterol 5/5 μg, tiotropium 5 μg, and olodaterol 5 μg. Primary end points at 12 weeks (OTEMTO) or 24 weeks (TONADO) included St George’s Respiratory Questionnaire (SGRQ) total score, forced expiratory volume in 1 second (FEV1) area under the curve from 0 hour to 3 hours (AUC0–3) response, and trough FEV1 response. Results A total of 1,621 patients were randomized (40 years to <65 years, n=749; 65 years to <75 years, n=674; 75 years to <85 years, n=186; ≥85 years, n=12) in OTEMTO and 5,162 patients (40 years to <65 years, n=2,654; 65 years to <75 years, n=1,967; 75 to <85 years, n=528; ≥85 years, n=13) in TONADO. FEV1 AUC0–3 and trough FEV1 responses improved with tiotropium + olodaterol 5/5 μg at 12 weeks and 24 weeks compared to monotherapies or placebo for all age groups. SGRQ scores generally improved with tiotropium + olodaterol 5/5 μg after 12 weeks in OTEMTO and improved after 24 weeks in all age groups in TONADO. In all age groups receiving tiotropium + olodaterol 5/5 μg compared to monotherapies or placebo, transition dyspnea index scores generally improved, while rescue medication usage improved. Conclusion No differences were noted in relative responses to treatment or safety when using tiotropium + olodaterol 5/5 μg compared to monotherapies or placebo across all age groups.
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Affiliation(s)
- Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI
| | | | | | - Lars Grönke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein
| | - Florian Voß
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
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192
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Abstract
Current guidelines recommend inhaled pharmacologic therapy as the preferred route of administration for treating COPD. Bronchodilators (β2-agonists and antimuscarinics) are the mainstay of pharmacologic therapy in patients with COPD, with long-acting agents recommended for patients with moderate to severe symptoms or those who are at a higher risk for COPD exacerbations. Dry powder inhalers and pressurized metered dose inhalers are the most commonly used drug delivery devices, but they may be inadequate in various clinical scenarios (eg, the elderly, the cognitively impaired, and hospitalized patients). As more drugs become available in solution formulations, patients with COPD and their caregivers are becoming increasingly satisfied with nebulized drug delivery, which provides benefits similar to drugs delivered by handheld inhalers in both symptom relief and improved quality of life. This article reviews recent innovations in nebulized drug delivery and the important role of nebulized therapy in the treatment of COPD.
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Affiliation(s)
- Donald P Tashkin
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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193
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Jones B, Donovan C, Liu G, Gomez HM, Chimankar V, Harrison CL, Wiegman CH, Adcock IM, Knight DA, Hirota JA, Hansbro PM. Animal models of COPD: What do they tell us? Respirology 2016; 22:21-32. [DOI: 10.1111/resp.12908] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Bernadette Jones
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
| | - Chantal Donovan
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
| | - Gang Liu
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
| | - Henry M. Gomez
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
| | - Vrushali Chimankar
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
| | - Celeste L. Harrison
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
| | - Cornelis H. Wiegman
- The Airways Disease Section, National Heart and Lung Institute; Imperial College London; London UK
| | - Ian M. Adcock
- The Airways Disease Section, National Heart and Lung Institute; Imperial College London; London UK
| | - Darryl A. Knight
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
| | - Jeremy A. Hirota
- James Hogg Research Centre; University of British Columbia; Vancouver British Columbia Canada
| | - Philip M. Hansbro
- Priority Research Centre for Healthy Lungs; Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia; London UK
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194
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Beeh KM. The Role of Bronchodilators in Preventing Exacerbations of Chronic Obstructive Pulmonary Disease. Tuberc Respir Dis (Seoul) 2016; 79:241-247. [PMID: 27790275 PMCID: PMC5077727 DOI: 10.4046/trd.2016.79.4.241] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 08/19/2016] [Accepted: 08/30/2016] [Indexed: 11/26/2022] Open
Abstract
Bronchodilators are the cornerstone of symptomatic chronic obstructive pulmonary disease (COPD) treatment. They are routinely recommended for symptom reduction, with a preference of long-acting over short-acting drugs. Bronchodilators are classified into two classes based on distinct modes of action, i.e., long-acting antimuscarinics (LAMA, once-daily and twice-daily), and long-acting β2-agonists (LABA, once-daily and twice-daily). In contrast to asthma management, evidence supports the efficacy of both classes of long-acting bronchodilators as monotherapy in preventing COPD exacerbations, with greater efficacy of LAMA drugs versus LABAs. Several novel LAMA/LABA fixed dose combination inhalers are currently approved for COPD maintenance treatment. These agents show superior symptom control to monotherapies, and some of these combinations have also demonstrated superior efficacy in exacerbation prevention versus monotherapies, or combinations of inhaled corticosteroids plus LABA. This review summarizes the current data on clinical effectiveness of bronchodilators alone or in combination to prevent exacerbations of COPD.
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Affiliation(s)
- Kai M Beeh
- Insaf Respiratory Research Institute, Wiesbaden, Germany
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195
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Halpin DMG, Kerkhof M, Soriano JB, Mikkelsen H, Price DB. Eligibility of real-life patients with COPD for inclusion in trials of inhaled long-acting bronchodilator therapy. Respir Res 2016; 17:120. [PMID: 27663386 PMCID: PMC5034631 DOI: 10.1186/s12931-016-0433-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 09/17/2016] [Indexed: 11/21/2022] Open
Abstract
Background Management guidelines of chronic obstructive pulmonary disease (COPD) are mainly based on results of randomised controlled trials (RCTs), but some authors have suggested limited representativeness of patients included in these trials. No previous studies have applied the full range of selection criteria to a broad COPD patient population in a real-life setting. Methods We identified all RCTs of inhaled long-acting bronchodilator therapy, during 1999–2013, at ClinicalTrials.gov and translated trial selection criteria into definitions compatible with electronic medical records. Eligibility was calculated for each RCT by applying these criteria to a uniquely representative, well-characterised population of patients with COPD from the Optimum Patient Care Research Database (OPCRD). Results Median eligibility of 36 893 patients with COPD for participation in 31 RCTs was 23 % (interquartile range 12–38). Two studies of olodaterol showed the highest eligibility of 55 and 58 %. Conversely, the lowest eligibility was observed in two studies that required a history of exacerbations in the past year (3.5 and 3.9 %). For the patient subgroup with modified Medical Research Council score ≥2, the overall median eligibility was 27 %. Conclusions By applying an extensive range of RCT selection criteria to a large, representative COPD patient population, this study highlights that the interpretation of results from RCTs must take into account that RCT participants are variably, but generally more representative of patients in the community than previously believed. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0433-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David M G Halpin
- Department of Respiratory Medicine, Royal Devon & Exeter Hospital, Exeter, EX2 5DW, UK
| | - Marjan Kerkhof
- Research in Real-Life Ltd, 5a Coles Lane, Oakington, Cambridge, CB24 3BA, UK.
| | - Joan B Soriano
- Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Cátedra UAM-Linde, Madrid, Spain
| | - Helga Mikkelsen
- Cambridge Research Support Ltd, Warren House, Aylsham, NR11 5UN, UK
| | - David B Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
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196
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Involvement of Ca 2+ Signaling in the Synergistic Effects between Muscarinic Receptor Antagonists and β₂-Adrenoceptor Agonists in Airway Smooth Muscle. Int J Mol Sci 2016; 17:ijms17091590. [PMID: 27657061 PMCID: PMC5037855 DOI: 10.3390/ijms17091590] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/02/2016] [Accepted: 09/08/2016] [Indexed: 12/25/2022] Open
Abstract
Long-acting muscarinic antagonists (LAMAs) and short-acting β2-adrenoceptor agonists (SABAs) play important roles in remedy for COPD. To propel a translational research for development of bronchodilator therapy, synergistic effects between SABAs with LAMAs were examined focused on Ca2+ signaling using simultaneous records of isometric tension and F340/F380 in fura-2-loaded tracheal smooth muscle. Glycopyrronium (3 nM), a LAMA, modestly reduced methacholine (1 μM)-induced contraction. When procaterol, salbutamol and SABAs were applied in the presence of glycopyrronium, relaxant effects of these SABAs are markedly enhanced, and percent inhibition of tension was much greater than the sum of those for each agent and those expected from the BI theory. In contrast, percent inhibition of F340/F380 was not greater than those values. Bisindolylmaleimide, an inhibitor of protein kinase C (PKC), significantly increased the relaxant effect of LAMA without reducing F340/F380. Iberiotoxin, an inhibitor of large-conductance Ca2+-activated K+ (KCa) channels, significantly suppressed the effects of these combined agents with reducing F340/F380. In conclusion, combination of SABAs with LAMAs synergistically enhances inhibition of muscarinic contraction via decreasing both Ca2+ sensitization mediated by PKC and Ca2+ dynamics mediated by KCa channels. PKC and KCa channels may be molecular targets for cross talk between β2-adrenoceptors and muscarinic receptors.
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197
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van Boven JF, Kocks JW, Postma MJ. Cost-effectiveness and budget impact of the fixed-dose dual bronchodilator combination tiotropium-olodaterol for patients with COPD in the Netherlands. Int J Chron Obstruct Pulmon Dis 2016; 11:2191-2201. [PMID: 27703341 PMCID: PMC5036592 DOI: 10.2147/copd.s114738] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose The fixed-dose dual bronchodilator combination (FDC) of tiotropium and olodaterol showed increased effectiveness regarding lung function and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD) compared with the use of its mono-components. Yet, while effectiveness and safety have been shown, the health economic implication of this treatment is still unknown. The aim of this study was to assess the cost–utility and budget impact of tiotropium–olodaterol FDC in patients with moderate to very severe COPD in the Netherlands. Patients and methods A cost–utility study was performed, using an individual-level Markov model. To populate the model, individual patient-level data (age, height, sex, COPD duration, baseline forced expiratory volume in 1 second) were obtained from the tiotropium–olodaterol TOnado trial. In the model, forced expiratory volume in 1 second and patient-level data were extrapolated to utility and survival, and treatment with tiotropium–olodaterol FDC was compared with tiotropium. Cost–utility analysis was performed from the Dutch health care payer’s perspective using a 15-year time horizon in the base-case analysis. The standard Dutch discount rates were applied (costs: 4.0%; effects: 1.5%). Both univariate and probabilistic sensitivity analyses were performed. Budget impact was annually assessed over a 5-year time horizon, taking into account different levels of medication adherence. Results As a result of cost increases, combined with quality-adjusted life-year (QALY) gains, results showed that tiotropium–olodaterol FDC had an incremental cost-effectiveness ratio of €7,004/QALY. Without discounting, the incremental cost-effectiveness ratio was €5,981/QALY. Results were robust in univariate and probabilistic sensitivity analyses. Budget impact was estimated at €4.3 million over 5 years assuming 100% medication adherence. Scenarios with 40%, 60%, and 80% adherence resulted in lower 5-year incremental cost increases of €1.7, €2.6, and €3.4 million, respectively. Conclusion Tiotropium–olodaterol FDC can be considered a cost-effective treatment under current Dutch cost-effectiveness thresholds.
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Affiliation(s)
- Job Fm van Boven
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics; Department of General Practice, Groningen Research Institute for Asthma and COPD (GRIAC)
| | - Janwillem Wh Kocks
- Department of General Practice, Groningen Research Institute for Asthma and COPD (GRIAC)
| | - Maarten J Postma
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics; Institute of Science in Healthy Aging & healthcaRE (SHARE); Department of Epidemiology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, the Netherlands
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198
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Mahler DA, Keininger DL, Mezzi K, Fogel R, Banerji D. Efficacy of Indacaterol/Glycopyrronium in Patients with COPD Who Have Increased Dyspnea with Daily Activities. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2016; 3:758-768. [PMID: 28848901 PMCID: PMC5556959 DOI: 10.15326/jcopdf.3.4.2016.0138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 12/12/2022]
Abstract
Introduction: The Global initiative for chronic Obstructive Lung Disease (GOLD) recommends treating patients with chronic obstructive pulmonary disease (COPD) based on a combined assessment of symptom severity and airflow limitation and/or exacerbation risk. According to GOLD, patients with mild-to-moderate airflow limitation and distressing symptoms such as dyspnea should be treated with a long-acting beta2-agonist (LABA) or a long-acting muscarinic antagonist (LAMA). If symptoms persist on monotherapy, GOLD recommends a combination of bronchodilators (LABA/LAMA). Methods: We performed a post-hoc analysis of data from two 26-week, prospective clinical trials to investigate the effect of treating patients with moderate-to-severe dyspnea with the once-daily LABA/LAMA combination indacaterol/glycopyrronium (IND/GLY) 110/50 µg compared with placebo, once-daily tiotropium 18 µg, and twice-daily salmeterol/fluticasone propionate (SFC) 50/500 µg. In this analysis, a Baseline Dyspnea Index (BDI) score ≤7 was used to identify dyspneic patients. Results: In dyspneic patients, IND/GLY significantly improved Transition Dyspnea Index (TDI) total scores compared with tiotropium (0.59 units; p<0.05) and SFC (0.97 units; p<0.05), and significantly increased the likelihood of a patient achieving a 1-unit improvement in TDI compared with tiotropium (odds ratio [OR] 1.87; p<0.05). IND/GLY also significantly improved trough forced expiratory volume in 1 second (FEV1) compared with tiotropium and SFC (p<0.001 and p<0.0001, respectively), and significantly reduced rescue medication use compared with tiotropium (p<0.001). Conclusions: Our analysis indicates that IND/GLY provides additional improvements in dyspnea and lung function compared with tiotropium and SFC in dyspneic patients.
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Affiliation(s)
- Donald A. Mahler
- Professor Emeritus, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Donal Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
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199
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Ichinose M, Taniguchi H, Takizawa A, Grönke L, Loaiza L, Voß F, Zhao Y, Fukuchi Y. The efficacy and safety of combined tiotropium and olodaterol via the Respimat(®) inhaler in patients with COPD: results from the Japanese sub-population of the Tonado(®) studies. Int J Chron Obstruct Pulmon Dis 2016; 11:2017-27. [PMID: 27621608 PMCID: PMC5010080 DOI: 10.2147/copd.s110389] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The efficacy and safety of once-daily tiotropium + olodaterol (T+O) maintenance treatment was demonstrated in the large, multinational, replicate, randomized, Phase III, Tonado(®) 1 (NCT01431274) and 2 (NCT01431287) studies in patients with moderate to very severe COPD. However, there may be racial differences in the effects of T+O on lung function in patients with COPD. METHODS In this Tonado(®) subgroup analysis, we assessed efficacy and safety of T+O in Japanese participants. RESULTS Versus the overall population, the 413 Japanese patients randomized and treated were slightly older, with more men, lower body mass index, lower baseline St George's Respiratory Questionnaire (SGRQ) scores, fewer current smokers, but with higher pack-year smoking history. A lower proportion of Japanese patients used inhaled corticosteroids, short-acting muscarinic antagonists, or short- or long-acting β-adrenergic agonists at baseline, but use of long-acting muscarinic antagonists was higher. At Week 24, mean improvements with T+O 5/5 μg in forced expiratory volume in 1 second area under the curve from 0-3 hours response were 151 mL versus olodaterol and 134 mL versus tiotropium 5 μg; mean improvements with T+O 2.5/5 μg were 87 mL versus olodaterol and 70 mL versus tiotropium 2.5 μg. Mean improvements with T+O 5/5 μg in trough forced expiratory volume in 1 second were 131 mL versus olodaterol and 108 mL versus tiotropium 5 μg; mean improvements with T+O 2.5/5 μg were 60 mL versus olodaterol and 47 mL versus tiotropium 2.5 μg. SGRQ scores improved from baseline to a greater extent with both doses of T+O versus monotherapies. Responses were similar in the overall population. Adverse-event incidence was generally balanced across treatment groups. CONCLUSION Consistent with results from the overall population, T+O 5/5 μg was superior to each monotherapy for lung function and SGRQ in the Japanese sub-population of patients with COPD in Tonado(®).
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Affiliation(s)
- Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan
| | | | - Lars Grönke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Lazaro Loaiza
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Florian Voß
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Yihua Zhao
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
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Pascoe S, Wu W, Zhu CQ, Singh D. Bronchodilator reversibility in patients with COPD revisited: short-term reproducibility. Int J Chron Obstruct Pulmon Dis 2016; 11:2035-40. [PMID: 27621609 PMCID: PMC5010081 DOI: 10.2147/copd.s108723] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Categorization of patients with COPD as reversible or nonreversible to a bronchodilator may change over time. This post hoc analysis aimed to determine if an individual's reversibility, when treated as a continuous variable, could predict his/her future response to two short-acting bronchodilators: albuterol and ipratropium. The analysis was completed using data from a 4-week, randomized, open-label, two-period crossover study (NCT01691482; GSK study DB2114956). Patients received albuterol (doses: UK =4×100 μg/puff; US =4×90 μg/puff) followed 1 hour later by ipratropium (4×20 μg/puff) or vice versa during treatment Period 1. The order of treatments was reversed during Period 2. Predefined efficacy end points included pre- and post-bronchodilator forced expiratory volume in 1 second. The correlation coefficient between bronchodilator response on Days 1 and 10 was investigated, as well as the correlation between treatment response on Day 1 and the mean treatment response on Days 5-10, for each individual patient. Bronchodilator response to albuterol on Day 1 was strongly correlated with that on Day 10 (r=0.64; n=53). The correlation coefficient of bronchodilator treatment response on Day 1 and Days 5-10 was 0.78 (P<0.001; n=53) and 0.76 (P<0.001; n=54) for albuterol and ipratropium, respectively. A single measurement of the initial bronchodilator response to albuterol or ipratropium was, therefore, highly correlated with the subsequent mean bronchodilator response over 5-10 days, demonstrating its potential usefulness for future treatment decisions.
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Affiliation(s)
| | - Wei Wu
- PAREXEL International, Research Triangle Park, NC, USA
| | | | - Dave Singh
- Medicines Evaluation Unit, University Hospital of South Manchester NHS Foundation Trust, University of Manchester, Manchester, UK
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