151
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Affiliation(s)
- Christine Jenkins
- Senior staff specialist, Department of Thoracic Medicine, Concord Hospital
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152
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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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153
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Donohue JF, Betts KA, Du EX, Altman P, Goyal P, Keininger DL, Gruenberger JB, Signorovitch JE. Comparative efficacy of long-acting β2-agonists as monotherapy for chronic obstructive pulmonary disease: a network meta-analysis. Int J Chron Obstruct Pulmon Dis 2017; 12:367-381. [PMID: 28176892 PMCID: PMC5261557 DOI: 10.2147/copd.s119908] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Long-acting β2-agonists (LABAs) have demonstrated efficacy in patients with COPD in clinical trials. The purpose of this study was to assess the comparative efficacy of all available dosages of all LABA monotherapies using a network meta-analysis. METHODS A systematic literature review identified 33 randomized controlled trials of LABA monotherapies (salmeterol 50 μg twice daily [BID]; formoterol 12 μg BID; indacaterol 75, 150, and 300 μg once daily [OD]; olodaterol 5 and 10 μg OD, and vilanterol 25 μg OD). Clinical efficacy was evaluated at 12 and 24 weeks in terms of trough forced expiratory volume in 1 second (FEV1), transition dyspnea index focal score, St George's Respiratory Questionnaire total score, and rate of COPD exacerbations. The relative effectiveness of all LABA monotherapies was estimated by Bayesian network meta-analysis. RESULTS At 12 and 24 weeks, indacaterol 300 and 150 μg OD were associated with statistically significant improvement in trough FEV1 compared to all other LABA monotherapies; vilanterol 25 μg OD was superior to formoterol 12 μg BID. At 12 weeks, indacaterol 75 μg OD was associated with significant improvement in trough FEV1 compared to formoterol 12 μg BID and olodaterol (5 and 10 μg OD); salmeterol 50 μg BID was superior to formoterol 12 μg BID and olodaterol 5 μg OD. Indacaterol 300 μg OD was also associated with significant improvement in transition dyspnea index focal score compared to all other LABAs at 12 or 24 weeks. Indacaterol 150 μg OD had significantly better results in exacerbation rates than olodaterol 5 μg and olodaterol 10 μg OD. CONCLUSION Indacaterol 300 μg, followed by 150 and 75 μg, were the most effective LABA monotherapies for moderate to severe COPD.
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Affiliation(s)
- James F Donohue
- Department of Pulmonary Diseases and Critical Care Medicine, The University of North Carolina, Chapel Hill, NC
| | | | | | - Pablo Altman
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
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154
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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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155
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Salomon J, Stolz D, Domenighetti G, Frey JG, Turk AJ, Azzola A, Sigrist T, Fitting JW, Schmidt U, Geiser T, Wild C, Kostikas K, Clemens A, Brutsche M. Indacaterol and glycopyrronium versus indacaterol on body plethysmography measurements in COPD-a randomised controlled study. Respir Res 2017; 18:13. [PMID: 28077140 PMCID: PMC5225517 DOI: 10.1186/s12931-016-0498-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 12/05/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Dual bronchodilator therapy is recommended for symptomatic patients with chronic obstructive pulmonary disease (COPD). There are limited data on effects of a combination of two long-acting bronchodilators on lung function including body plethysmography. METHODS This multicentre, randomised, double-blind, single-dose, cross-over, placebo-controlled study evaluated efficacy and safety of the free combination of indacaterol maleate (IND) and glycopyrronium bromide (GLY) versus IND alone on spirometric and body plethysmography parameters, including inspiratory capacity (IC), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), total lung capacity (TLC) and airway resistance (Raw) in moderate-to-severe COPD patients. RESULTS Seventy-eight patients with FEV1 % pred. (mean ± SD) 56 ± 13% were randomised. The combination of IND + GLY versus IND presented a numerically higher peak-IC (Δ = 0.076 L, 95% confidence interval [CI]: -0.010 - 0.161 L; p = 0.083), with a statistically significant difference in mean IC over 4 h (Δ = 0.054 L, 95%CI 0.022 - 0.086 L; p = 0.001). FEV1, FVC and Raw, but not TLC, were consistently significantly improved by IND + GLY compared to IND alone. Safety profiles of both treatments were comparable. CONCLUSION The free combination of IND + GLY improved lung function parameters as evaluated by spirometry and body plethysmography, with a similar safety profile compared to IND alone. TRIAL REGISTRATION NCT01699685.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ulrich Schmidt
- Kliniken Valens, Rehabilitation Centre, Walenstadtberg, St. Gallen, Switzerland
| | | | - Corinne Wild
- Novartis Pharma Schweiz AG, Rotkreuz, Switzerland
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156
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Cazzola M, Ora J, Puxeddu E, Rogliani P. Indacaterol/Glycopyrronium Combination for COPD. Pulm Ther 2017. [DOI: 10.1007/s41030-016-0024-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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157
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Baarnes CB, Kjeldgaard P, Nielsen M, Miravitlles M, Ulrik CS. Identifying possible asthma-COPD overlap syndrome in patients with a new diagnosis of COPD in primary care. NPJ Prim Care Respir Med 2017; 27:16084. [PMID: 28055002 PMCID: PMC5214698 DOI: 10.1038/npjpcrm.2016.84] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 08/05/2016] [Accepted: 09/09/2016] [Indexed: 01/03/2023] Open
Abstract
The asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) remains poorly characterised. Our aim was to describe an algorithm for identifying possible ACOS in adults with newly diagnosed COPD in primary care. General practitioners (n=241) consecutively recruited subjects ⩾35 years, with tobacco exposure, at least one respiratory symptom and no previous diagnosis of obstructive lung disease. Possible ACOS was defined as chronic airflow obstruction, i.e., post-bronchodilator (BD) forced expiratory volume 1/forced vital capacity (FEV1/FVC) ratio<0.70, combined with wheeze (ACOS wheeze) and/or significant BD reversibility (ACOS BD reversibility). Of 3,875 (50% females, mean age 57 years) subjects screened, 700 (18.1%) were diagnosed with COPD, i.e., symptom(s), tobacco exposure and chronic airflow obstruction. Indications for ACOS were found in 264 (38%) of the COPD patients. The prevalence of ACOS wheeze and ACOS BD reversibility was 27% (n=190) and 16% (n=113), respectively (P<0.001), and only 6% (n=39) of the COPD patients fulfilled both criteria for ACOS. Patients with any ACOS were younger (P=0.04), had more dyspnoea (P<0.001), lower FEV1%pred (67% vs. 74%; P<0.001) and lower FEV1/FVC ratio (P=0.001) compared with COPD-only patients. Comparing subjects fulfilling both criteria for ACOS with those fulfilling criteria for ACOS wheeze only (n=151) and those fulfilling criteria for ACOS BD reversibility only (n=74) revealed no significant differences. Irrespective of the applied ACOS definition, no significant difference in life-time tobacco exposure was found between ACOS- and COPD-only patients. In subjects with a new diagnosis of COPD, the prevalence of ACOS is high. When screening for COPD in general practice among patients with no previous diagnosis of obstructive lung disease, patients with possible ACOS may be identified by self-reported wheeze and/or BD reversibility.
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Affiliation(s)
| | - Peter Kjeldgaard
- Department of Pulmonary Medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - Mia Nielsen
- Department of Pulmonary Medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - Marc Miravitlles
- Department of Pneumology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Charlotte Suppli Ulrik
- Department of Pulmonary Medicine, Hvidovre Hospital, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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158
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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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159
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Vogelmeier C, Zhong N, Humphries MJ, Mezzi K, Fogel R, Bader G, Patalano F, Banerji D. Indacaterol/glycopyrronium in symptomatic patients with COPD (GOLD B and GOLD D) versus salmeterol/fluticasone: ILLUMINATE/LANTERN pooled analysis. Int J Chron Obstruct Pulmon Dis 2016; 11:3189-3197. [PMID: 28008244 PMCID: PMC5167461 DOI: 10.2147/copd.s116786] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Indacaterol/glycopyrronium (IND/GLY) is approved for maintenance treatment of adult patients with COPD. This post hoc analysis explored the efficacy and safety of IND/GLY versus salmeterol/fluticasone (SFC) in symptomatic (Global Initiative for Chronic Obstructive Lung Disease [GOLD] B and GOLD D) patients with moderate-to-severe COPD. PATIENTS AND METHODS Data from LANTERN and ILLUMINATE studies were pooled and analyzed. In both studies, symptomatic COPD patients were randomized to once-daily IND/GLY 110 μg/50 μg or twice-daily SFC 50 μg/500 μg. End points were pre-dose trough forced expiratory volume in one second (FEV1), standardized area under the curve for FEV1 from 0 to 12 hours (FEV1 AUC0-12 hours), peak FEV1, peak forced vital capacity (FVC), pre-dose trough FVC, Transition Dyspnea Index (TDI) total score, St George's Respiratory Questionnaire total score, rescue medication use and safety. RESULTS A total of 1,263 patients were classified as either GOLD B (n=809) or GOLD D (n=454). At week 26, IND/GLY demonstrated statistically significant improvement in all lung function parameters versus SFC in patients in both the GOLD B and GOLD D subgroups. TDI total score and rescue medication use were significantly improved with IND/GLY versus SFC in the overall population and in the GOLD B (TDI total score only) and GOLD D (rescue medication only) subgroups. IND/GLY also reduced the rate of exacerbations in the pooled population. Overall safety profile was comparable with a higher incidence of pneumonia in the SFC-treated group. CONCLUSION In this pooled analysis, IND/GLY demonstrated superior efficacy compared with SFC in patients in the GOLD B and GOLD D subgroups and supported its use in symptomatic COPD patients.
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Affiliation(s)
- Claus 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
| | - Nanshan Zhong
- State Key Laboratory, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou
| | | | | | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Donald Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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160
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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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161
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Falk J, Dik N, Bugden S. An evaluation of early medication use for COPD: a population-based cohort study. Int J Chron Obstruct Pulmon Dis 2016; 11:3101-3108. [PMID: 27994449 PMCID: PMC5153270 DOI: 10.2147/copd.s123643] [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
Purpose The aim of this study was to evaluate the first initiation, sequence of addition, and appropriate prescribing of COPD medications in Manitoba, Canada. Patients and methods A population-based cohort study of COPD medication use was conducted using administrative health care data (1997–2012). Those aged ≥35 years with COPD based on three or more COPD-related outpatient visits over a rolling 24-month window or at least one COPD-related hospitalization were included. The first medication(s) dispensed on or after the date of COPD diagnosis were determined based on pharmacy claims. The next medication(s) in sequence were determined to be additions or switches to the previous regimen. Evaluation of guideline-based appropriateness to receive inhaled corticosteroids (ICS) was based on exacerbation history and past medication use. Results Of 13,369 patients dispensed COPD medications after diagnosis, 66.0% were dispensed short-acting bronchodilators as first medications. Although long-acting bronchodilators alone were uncommonly used as first or subsequent medications, ICS were dispensed as first medications in 28.2% of patients. Over the study period, use of short-acting bronchodilators as first medications declined from 70.6% to 59.4% (P<0.0001), whereas the use of ICS as a first medication increased from 23.5% to 34.4% (P<0.0001). Dispensation of an ICS plus a long-acting β-agonist increased dramatically from 1.2% to 27.3% (P<0.0001). By the end of the study period, the majority of patients (53.3%) were being initiated on two or more medications. Of 5,823 patients dispensed an ICS, 52.4% met Canadian guideline criteria for initiating an ICS, whereas 0.3% met Global Initiative for Chronic Obstructive Lung Disease guideline criteria. Conclusion The use of first-line medications has declined over time, replaced primarily by combination inhalers prescribed early without prior trials of appropriate next step medications. This, along with an increasingly predominant use of multiple first medications, indicates a significant degree of medication burden in this already complex patient population.
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Affiliation(s)
- Jamie Falk
- College of Pharmacy, Rady Faculty of Health Sciences
| | - Natalia Dik
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Shawn Bugden
- College of Pharmacy, Rady Faculty of Health Sciences
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162
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Jones PW, Rennard S, Tabberer M, Riley JH, Vahdati-Bolouri M, Barnes NC. Interpreting patient-reported outcomes from clinical trials in COPD: a discussion. Int J Chron Obstruct Pulmon Dis 2016; 11:3069-3078. [PMID: 27994447 PMCID: PMC5153282 DOI: 10.2147/copd.s117378] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
One of the challenges faced by the practising physician is the interpretation of patient-reported outcomes (PROs) in clinical trials and the relevance of such data to their patients. This is especially true when caring for patients with progressive diseases such as COPD. In an attempt to incorporate the patient perspective, many clinical trials now include assessments of PROs. These are formalized methods of capturing patient-centered information. Given the importance of PROs in evaluating the potential utility of an intervention for a patient with COPD, it is important that physicians are able to critically interpret (and critique) the results derived from them. Therefore, in this paper, a series of questions is posed for the practising physician to consider when reviewing the treatment effectiveness as assessed by PROs. The focus is on the St George's Respiratory Questionnaire for worked examples, but the principles apply equally to other symptom-based questionnaires. A number of different ways of presenting PRO data are discussed, including the concept of the minimum clinically important difference, whether there is a ceiling effect to PRO results, and the strengths and weaknesses of responder analyses. Using a worked example, the value of including a placebo arm in a study is illustrated, and the influence of the study on PRO results is considered, in terms of the design, patient withdrawal, and the selection of the study population. For the practising clinician, the most important consideration is the importance of individualization of treatment (and of treatment goals). To inform such treatment, clinicians need to critically review PRO data. The hope is that the questions posed here will help to build a framework for this critical review.
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Affiliation(s)
- Paul W Jones
- Institute for Infection and Immunity, University of London, London
- Global Respiratory Franchise, GlaxoSmithKline, Uxbridge, UK
| | - Stephen Rennard
- Division of Pulmonary, Critical Care, Sleep and Allergy, Nebraska Medical Center, Omaha, NE, USA
- Clinical Discovery Unit, AstraZeneca, Cambridge
| | | | - John H Riley
- Global Respiratory Franchise, GlaxoSmithKline, Uxbridge, UK
| | | | - Neil C Barnes
- Global Respiratory Franchise, GlaxoSmithKline, Uxbridge, UK
- William Harvey Institute, Bart’s and the London School of Medicine and Dentistry, London, UK
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163
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Karur P, Singh D. Optimum treatment for chronic obstructive pulmonary disease exacerbation prevention. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:531. [PMID: 28149892 DOI: 10.21037/atm.2016.11.58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Pradeep Karur
- Centre for Respiratory Medicine and Allergy, Medicines Evaluation Unit, University of Manchester and University Hospital of South Manchester, Manchester, UK
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Medicines Evaluation Unit, University of Manchester and University Hospital of South Manchester, Manchester, UK
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164
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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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165
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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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166
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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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167
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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: 33] [Impact Index Per Article: 4.1] [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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168
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Improving the Management of COPD in Women. Chest 2016; 151:686-696. [PMID: 27816445 DOI: 10.1016/j.chest.2016.10.031] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/13/2016] [Accepted: 10/17/2016] [Indexed: 01/15/2023] Open
Abstract
COPD is a highly debilitating disease that represents a substantial and growing health burden in women. There is increasing evidence for sex-related differences in COPD risk, progression, and outcomes. However, the disease receives scant attention as a women's health issue. Thus, a multifaceted approach is required to address COPD in women, including greater awareness, minimization of risk, and further elucidation of the sex-specific factors (biological and cultural) that affect risk, disease progression, and treatment success. This article reviews the current literature on the topic and provides suggestions for achieving better outcomes for the millions of women with COPD worldwide.
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169
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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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170
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Hashimoto S, Ikeuchi H, Murata S, Kitawaki T, Ikeda K, Banerji D. Efficacy and safety of indacaterol/glycopyrronium in Japanese patients with COPD: a subgroup analysis from the SHINE study. Int J Chron Obstruct Pulmon Dis 2016; 11:2543-2551. [PMID: 27785010 PMCID: PMC5066848 DOI: 10.2147/copd.s111408] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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 COPD-related deaths are increasing in Japan, with ~5.3 million people at risk. METHODS The SHINE was a 26-week, multicenter, randomized, double-blind, parallel-group study that evaluated safety and efficacy of indacaterol (IND)/glycopyrronium (GLY) 110/50 μg once daily (od) compared with GLY 50 μg od, IND 150 μg od, open-label tiotropium (TIO) 18 μg od, and placebo. The primary end point was trough forced expiratory volume in 1 second (FEV1) at Week 26. Other key end points included peak FEV1, area under the curve for FEV1 from 5 minutes to 4 hours (FEV1 AUC5 min-4 h), Transition Dyspnea Index focal score, St George's Respiratory Questionnaire total score, and safety. Here, we present efficacy and safety of IND/GLY in the Japanese subgroup. RESULTS Of 2,144 patients from the SHINE study, 182 (8.5%) were Japanese and randomized to IND/GLY (n=42), IND (n=41), GLY (n=40), TIO (n=40), or placebo (n=19). Improvement in trough FEV1 from baseline was 190 mL with IND/GLY and treatment differences versus IND (90 mL), GLY (100 mL), TIO (90 mL), and placebo (280 mL) along with a rapid onset of action at Week 26. IND/GLY showed an improvement in FEV1 AUC5 min-4 h versus all comparators (all P<0.05). All the treatments were well tolerated and showed comparable effect on Transition Dyspnea Index focal score and St George's Respiratory Questionnaire total score. The effect of IND/GLY in the Japanese subgroup was consistent to overall SHINE study population. CONCLUSION IND/GLY demonstrated superior efficacy and comparable safety compared with its monocomponents, open-label TIO, and placebo and may be used as a treatment option for the management of moderate-to-severe COPD in Japanese patients.
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Affiliation(s)
- Shu Hashimoto
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | | | | | | | | | - Donald Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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171
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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: 16] [Impact Index Per Article: 2.0] [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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172
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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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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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174
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Singh D, Papi A, Corradi M, Pavlišová I, Montagna I, Francisco C, Cohuet G, Vezzoli S, Scuri M, Vestbo J. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial. Lancet 2016; 388:963-73. [PMID: 27598678 DOI: 10.1016/s0140-6736(16)31354-x] [Citation(s) in RCA: 282] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Few data are available for the efficacy of "triple therapy" with two long-acting bronchodilators and an inhaled corticosteroid in chronic obstructive pulmonary disease (COPD). We designed this study to assess efficacy of single-inhaler combination of an extra fine formulation of beclometasone dipropionate, formoterol fumarate, and glycopyrronium bromide (BDP/FF/GB) in COPD compared with beclometasone dipropionate and formoterol fumarate (BDP/FF) treatment. METHODS TRILOGY was a randomised, parallel group, double-blind, active-controlled study done in 159 sites across 14 countries. The sites were a mixture of primary, secondary, and tertiary care providers, and specialist investigation units. Eligible patients with COPD had post-bronchodilator forced expiratory volume in 1 s (FEV1) of lower than 50%, one or more moderate-to-severe COPD exacerbation in the previous 12 months, COPD Assessment Test total score of 10 or more, and a Baseline Dyspnea Index focal score of 10 or less. Patients who met the inclusion and exclusion criteria at screening entered a 2-week open-label run-in period where they received beclometasone dipropionate (100 μg) and formoterol fumarate (6 μg) in two actuations twice daily. Patients were then randomly assigned (1:1) with an interactive response technology system to either continue BDP (100 μg) and FF (6 μg) or step-up to BDP (100 μg), FF (6 μg), and GB (12·5 μg) in two actuations twice daily for 52 weeks via pressurised metered-dose inhaler. The three co-primary endpoints were pre-dose FEV1, 2-h post-dose FEV1, and Transition Dyspnea Index (TDI) focal score, all measured at week 26 in the intention-to-treat population (all patients who were randomly assigned and received at least one dose of study drug and had at least one post-baseline efficacy assessment). Safety outcomes were measured in the safety population (all patients who were randomly assigned and received at least one dose of study drug). Secondary endpoints included moderate-to-severe COPD exacerbation rate over 52 weeks. This study is registered with ClinicalTrials.gov number NCT01917331. FINDINGS Between March 21, 2014, and Jan 14, 2016, 1368 patients received either BDP/FF/GB (n=687) or BDP/FF (n=681). At week 26, BDP/FF/GB improved pre-dose FEV1 by 0·081 L (95% CI 0·052-0·109; p<0·001) and 2-h post-dose FEV1 by 0·117 L (0·086-0·147; p<0·001) compared with BDP/FF. Mean TDI focal scores at week 26 were 1·71 for BDP/FF/GB and 1·50 for BDP/FF, with a difference of 0·21 (95% CI -0·08 to 0·51; p=0·160). Adjusted annual moderate-to-severe exacerbation frequencies were 0·41 for BDP/FF/GB and 0·53 for BDP/FF (rate ratio 0·77 [95% CI 0·65-0·92]; p=0·005), corresponding to a 23% reduction in exacerbations with BDP/FF/GB compared with BDP/FF. Adverse events were reported by 368 (54%) patients with BDP/FF/GB and 379 (56%) with BDP/FF. One serious treatment-related adverse event occurred (atrial fibrillation) in a patient in the BDP/FF/GB group. INTERPRETATION We provide evidence for the clinical benefits of stepping up patients with COPD from an inhaled corticosteroid/long-acting β2-agonist combination treatment to triple therapy using a single inhaler. FUNDING Chiesi Farmaceutici SpA.
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Affiliation(s)
- Dave Singh
- Centre for Respiratory Medicine and Allergy, University of Manchester, Manchester, UK.
| | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | - Massimo Corradi
- Department of Clinical and Experimental Medicine, University of Parma, Italy
| | - Ilona Pavlišová
- Odborny Plicni Lekar, Poliklinika Moravsky Krumlov, Moravsky Krumlov, Czech Republic
| | | | | | | | - Stefano Vezzoli
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Mario Scuri
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Jørgen Vestbo
- Centre for Respiratory Medicine and Allergy, University of Manchester, Manchester, UK
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175
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Fabbri LM, Kerwin EM, Spangenthal S, Ferguson GT, Rodriguez-Roisin R, Pearle J, Sethi S, Orevillo C, Darken P, St Rose E, Fischer T, Golden M, Dwivedi S, Reisner C. Dose-response to inhaled glycopyrrolate delivered with a novel Co-Suspension™ Delivery Technology metered dose inhaler (MDI) in patients with moderate-to-severe COPD. Respir Res 2016; 17:109. [PMID: 27586537 PMCID: PMC5009486 DOI: 10.1186/s12931-016-0426-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/23/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This study forms part of the first complete characterization of the dose-response curve for glycopyrrolate (GP) delivered using Co-Suspension™ Delivery Technology via a metered dose inhaler (MDI). We examined the lower GP MDI dose range to determine an optimal dose for patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). METHODS This randomized, double-blind, chronic-dosing, balanced incomplete-block, placebo-controlled, crossover study compared six doses of GP MDI (18, 9, 4.6, 2.4, 1.2, and 0.6 μg, twice daily [BID]) with placebo MDI BID and open-label tiotropium dry powder inhaler (18 μg, once daily [QD]) in patients with moderate-to-severe COPD. Patients were randomized into 1 of 120 treatment sequences. Each sequence included 4 of 8 treatments administered for 14-day periods separated by 7- to 21-day washout periods. The primary efficacy endpoint was change from baseline in forced expiratory volume in 1 s area under the curve from 0 to 12 h (FEV1 AUC0-12) on Day 14. Secondary efficacy endpoints included peak change from baseline (post-dose) in FEV1 and inspiratory capacity (IC) on Days 1, 7, and 14; change from baseline in morning pre-dose trough FEV1 on Days 7 and 14; change from baseline in 12-h post-dose trough FEV1 on Day 14; time to onset of action (≥10 % improvement in mean FEV1) and the proportion of patients achieving ≥12 % improvement in FEV1 on Day 1; and pre-dose trough IC on Days 7 and 14. Safety and tolerability were also assessed. RESULTS GP MDI 18, 9, 4.6, and 2.4 μg demonstrated statistically significant and clinically relevant increases in FEV1 AUC0-12 compared with placebo MDI following 14 days of treatment (modified intent-to-treat population = 120). GP MDI 18 μg was non-inferior to open-label tiotropium for peak change in FEV1 on Day 1 and morning pre-dose trough FEV1 on Day 14. All doses of GP MDI were well tolerated with no unexpected safety findings. CONCLUSIONS These efficacy and safety results support GP MDI 18 μg BID as the most appropriate dose for evaluation in Phase III trials in patients with moderate-to-severe COPD. TRIAL REGISTRATION ClinicalTrials.gov NCT01566773 . Registered 27 March 2012.
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Affiliation(s)
- Leonardo M Fabbri
- Department of Medicine, University of Modena and Reggio Emilia, NOCSAE, AUSL di Modena, Via Giardini 1355, 41126, Modena, MO, Italy.
| | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Roberto Rodriguez-Roisin
- Servei de Pneumologia, Institut Clinic Respiratori, Hospital Clínic, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - James Pearle
- California Research Medical Group, Fullerton, CA, USA
| | - Sanjay Sethi
- University at Buffalo, State University of New York, Buffalo, NY, USA
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Singh D, Roche N, Halpin D, Agusti A, Wedzicha JA, Martinez FJ. Current Controversies in the Pharmacological Treatment of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2016; 194:541-9. [DOI: 10.1164/rccm.201606-1179pp] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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177
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Miravitlles M, Chapman KR, Chuecos F, Ribera A, Gil EG. The efficacy of aclidinium/formoterol on lung function and symptoms in patients with COPD categorized by symptom status: a pooled analysis. Int J Chron Obstruct Pulmon Dis 2016; 11:2041-53. [PMID: 27621610 PMCID: PMC5012634 DOI: 10.2147/copd.s114566] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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 Patients with chronic obstructive pulmonary disease (COPD) experience respiratory symptoms, which impair quality of life. This pooled analysis of two Phase III studies assessed the impact of aclidinium/formoterol on patients with COPD categorized by symptom status. METHODS Data were pooled from two 24-week, randomized, placebo-controlled studies of twice-daily aclidinium/formoterol 400/12 µg in moderate-to-severe COPD (ACLIFORM [NCT01462942] and AUGMENT [NCT01437397]). These post hoc analyses evaluated the efficacy of aclidinium/formoterol versus placebo or monotherapies in patients defined as less/more symptomatic by a) Evaluating Respiratory Symptoms (E-RS™) score ≥10/<10 and b) Baseline Dyspnea Index score <7/≥7. Endpoints included trough and 1-hour morning postdose forced expiratory volume in 1 second (FEV1), Transition Dyspnea Index, E-RS total score, early-morning and nighttime symptom severity, early-morning limitation of activities, and exacerbation rate. RESULTS Data for 3,394 patients were analyzed (mean age: 63.5 years; 60.5% male). In both definitions of less and more symptomatic patients, aclidinium/formoterol improved 1-hour morning postdose FEV1 from baseline at week 24 versus placebo (P<0.001) and both monotherapies (P<0.05). Aclidinium/formoterol improved trough FEV1 from baseline in both groups versus placebo (P<0.05) and formoterol (P<0.05); improvements were greater in more symptomatic patients. Improvements versus aclidinium were also observed in more symptomatic patients (P<0.05). Aclidinium/formoterol improved dyspnea, early-morning symptom severity, and limitation of activities versus placebo in both less and more symptomatic patients (P<0.001). In more symptomatic patients, aclidinium/formoterol also improved E-RS total score and severity of nighttime symptoms from baseline versus placebo and one or both monotherapies (P<0.05). The rate of moderate/severe exacerbations was reduced with aclidinium/formoterol versus placebo in more symptomatic patients. CONCLUSION Aclidinium/formoterol 400/12 µg provided consistent improvements in bronchodilation and symptoms versus monotherapies and reduced exacerbations versus placebo in more symptomatic patients with moderate-to-severe COPD, regardless of the definition used. Furthermore, patients with a low symptom burden achieved benefits with aclidinium/formoterol versus monotherapies in postdose FEV1, dyspnea, and early-morning symptoms.
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Affiliation(s)
- Marc Miravitlles
- Department of Pneumology, Vall d’Hebron University Hospital, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Kenneth R Chapman
- Asthma & Airway Centre, University Health Network, Toronto Western Hospital and University of Toronto, Toronto, ON, Canada
| | - Ferran Chuecos
- Global Medicines Development, AstraZeneca PLC, Barcelona, Spain
| | - Anna Ribera
- Global Medical Affairs, AstraZeneca PLC, Barcelona, Spain
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178
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Asai K, Hirata K, Hashimoto S, Fukuchi Y, Kitawaki T, Ikeda K, Fogel R, Banerji D. Efficacy and safety of indacaterol/glycopyrronium in Japanese patients with COPD: Pooled analysis of SHINE and ARISE. Respir Investig 2016; 54:428-435. [PMID: 27886854 DOI: 10.1016/j.resinv.2016.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/14/2016] [Accepted: 06/27/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND To better evaluate the efficacy and safety of the indacaterol/glycopyrronium (IND/GLY) fixed-dose combination versus tiotropium in Japanese patients, a pooled data analysis was conducted from the SHINE and ARISE studies, which were part of the IND/GLY clinical trial program. METHODS Japanese patients with moderate-to-severe COPD were included in the analysis. Efficacy in terms of pre-dose forced expiratory volume in one second (FEV1) at Week 12 and Week 24/26 (ARISE/SHINE) and FEV1 at 30min and 60min post-dose at Day 1, Week 12, and Week 24/26 was evaluated. Health status using the St. George׳s Respiratory Questionnaire (SGRQ) score, rescue medication use (number of puffs/day), safety, and tolerability were also assessed. RESULTS In total, 340 patients (IND/GLY, n=161; IND, n=41; GLY, n=40; tiotropium, n=79; and placebo, n=19) were included in the analysis that focused on comparing IND/GLY versus tiotropium since they were included in both studies. At Week 12 and Week 24/26, pre-dose FEV1 was significantly improved with IND/GLY compared with tiotropium (treatment differences=70mL and 80mL, respectively; both P≤0.001). FEV1 at 30min and 60min post-dose, the SGRQ total score, and rescue medication use were more statistically significant with IND/GLY than with tiotropium for all assessed time-points. The overall incidence of adverse events (AEs) and serious AEs was similar between the IND/GLY- and tiotropium-treated groups. CONCLUSIONS Compared to tiotropium, IND/GLY provided significant improvements in lung function, health status, and rescue medication use, while having a good safety profile in Japanese patients with moderate-to-severe COPD.
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Affiliation(s)
- Kazuhisa Asai
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan.
| | - Kazuto Hirata
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan.
| | | | - Yoshinosuke Fukuchi
- Department of Respiratory Medicine, Juntendo University School of Medicine, Tokyo, Japan.
| | | | | | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States.
| | - Donald Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States.
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179
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Ferguson GT, Taylor AF, Thach C, Wang Q, Schubert-Tennigkeit AA, Patalano F, Banerji D. Long-Term Maintenance Bronchodilation With Indacaterol/Glycopyrrolate Versus Indacaterol in Moderate-to-Severe COPD Patients: The FLIGHT 3 Study. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 3:716-728. [PMID: 28848898 DOI: 10.15326/jcopdf.3.4.2016.0131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: The objective of the FLIGHT3 study was to evaluate the long-term safety and efficacy of indacaterol/glycopyrrolate* (IND/GLY) versus an active comparator, IND, in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) over 52 weeks. Method: FLIGHT3 was a multicenter, randomized, double-blind, parallel-group, 52-week study. Patients were randomized (1:1:1) to IND/GLY (27.5/15.6 or 27.5/31.2 µg twice daily [b.i.d.]) or IND (75 µg once daily [o.d.]), delivered via the Neohaler® device. The primary objective was to evaluate the long-term safety and tolerability of IND/GLY versus IND in terms of adverse event (AE)-reporting rates in patients with moderate-to-severe COPD over 52 weeks. The secondary objective was to evaluate the long-term efficacy of IND/GLY versus IND in terms of pre-dose trough forced expiratory volume in 1 second (FEV1) and post-dose 1-h FEV1 over 52 weeks. Results: A total of 85.2% patients completed the study treatment. The overall incidence of AEs (and SAEs) was similar between treatments. Major adverse cardiovascular events (MACE) and/or cardiovascular (CV) events were comparable between treatment groups. The rate of discontinuation of the study treatment due to AEs was lower for IND/GLY than IND. Improvements in pre-dose trough FEV1 and post-dose 1-h FEV1 were consistently superior with IND/GLY than with IND over 52 weeks, demonstrating long-term maintenance of lung function. Conclusions: IND/GLY demonstrated a favorable long-term safety and tolerability profile and provided effective bronchodilation, with maintenance of lung function over 52 weeks in patients with moderate-to-severe COPD. These data support the safety and efficacy of IND/GLY as a treatment option for COPD. Trial registration: ClinTrials.gov identifier NCT01682863 *Glycopyrrolate 15.6 µg (excluding the bromide salt) is equivalent to 12.5 µg glycopyrronium.
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Affiliation(s)
- Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan-Farmington Hills
| | | | - Chau Thach
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Qian Wang
- Beijing Novartis Pharma Co. Ltd., Shanghai, China
| | | | | | - Donald Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
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180
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Zhong N, Wang C, Zhou X, Zhang N, Humphries M, Wang L, Patalano F, Banerji D. Efficacy and Safety of Indacaterol/Glycopyrronium (IND/GLY) Versus Salmeterol/Fluticasone in Chinese Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease: The Chinese Cohort from the LANTERN Study. COPD 2016; 13:686-692. [PMID: 27715335 DOI: 10.1080/15412555.2016.1182970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Inhaled indacaterol/glycopyrronium fixed-dose combination (IND/GLY) is approved in over 80 countries, including the EU, Japan, Australia and Switzerland and the US. The LANTERN study evaluated the efficacy of IND/GLY compared with inhaled long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) or salmeterol/fluticasone (SFC) in patients with moderate-to-severe COPD with a history of ≤1 exacerbation in the previous year. Here we present the efficacy and safety of IND/GLY versus SFC in the Chinese cohort from the LANTERN study. LANTERN was a 26-week, multicenter, randomized, double-blind, double-dummy, parallel-group study conducted in patients with moderate-to-severe COPD with a history of ≤1 exacerbation in the previous year. The patients were randomized (1:1) to once-daily IND/GLY (110/50 μg) or twice-daily SFC (50/500 μg). The primary endpoint was non-inferiority of IND/GLY versus SFC in terms of trough FEV1. Of the total 744 patients randomized in the LANTERN study, 598 (80.4%) were from Mainland China and randomized to IND/GLY (n = 298) or SFC (n = 300), and 553 (92.5%) completed the study. IND/GLY showed superiority over SFC with a statistically significant and clinically meaningful improvement in trough FEV1, FEV1 AUC0-4h, peak FEV1 and trough forced vital capacity (FVC) change from the baseline. Annualized rate of moderate or severe COPD exacerbations was significantly lower (43%) with IND/GLY compared with SFC (rate ratio: 0.57, p = 0.015). Overall, adverse events were lower for IND/GLY (34.6%) versus SFC (43.1%). IND/GLY was superior in achieving bronchodilation versus SFC in a Chinese subgroup of patients from this study. Clinicaltrials.gov identifier: NCT01709903.
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Affiliation(s)
- Nanshan Zhong
- a State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong , China
| | - Changzheng Wang
- b Institute of Respiratory Disease, Xin Qiao Hospital, Third Military Medical University , Chongqing City , Chongqing , China
| | - Xiangdong Zhou
- c Department of Respiratory Medicine , Southwest Hospital, Third Military Medical University , Chongqing City , Chongqing , China
| | - Nuofu Zhang
- a State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong , China
| | | | - Linda Wang
- d Beijing Novartis Pharma Co. Ltd. , Shanghai , China
| | | | - Donald Banerji
- f Novartis Pharmaceuticals Corporation , East Hanover , New Jersey , USA
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181
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Marin JM, Beeh KM, Clemens A, Castellani W, Schaper L, Saralaya D, Gunstone A, Casamor R, Kostikas K, Aalamian-Mattheis M. Early bronchodilator action of glycopyrronium versus tiotropium in moderate-to-severe COPD patients: a cross-over blinded randomized study (Symptoms and Pulmonary function in the moRnING). Int J Chron Obstruct Pulmon Dis 2016; 11:1425-34. [PMID: 27418815 PMCID: PMC4934556 DOI: 10.2147/copd.s106127] [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: 11/24/2022] Open
Abstract
Background Morning symptoms associated with COPD have a negative impact on patients’ quality of life. Long-acting bronchodilators with rapid onset may relieve patients’ symptoms. In the Symptoms and Pulmonary function in the moRnING study, we prospectively compared the rapid onset bronchodilator profile of glycopyrronium (GLY) and tiotropium (TIO) during the first few hours after dosing in patients with moderate-to-severe COPD. Methods Patients were randomized (1:1) to receive either once-daily GLY (50 μg) or TIO (18 μg) and corresponding placebos in a cross-over design for 28 days. The primary objective was to demonstrate the superiority of GLY versus TIO in area under the curve from 0 to 4 hours (AUC0-4h) forced expiratory volume in 1 second (FEV1) after the first dose. The secondary objective was to compare GLY versus TIO using the patient reported outcomes Morning COPD Symptoms Questionnaire 3 hours post-inhalation. Results One-hundred and twenty-six patients were randomized (male 70.2%; mean age 65.7 years) and 108 patients completed the study. On Day 1, GLY resulted in significantly higher FEV1 AUC0-4h after the first dose versus TIO (treatment difference [Δ], 0.030 L, 95% confidence interval 0.004–0.056, P=0.025). Improvements in morning COPD symptoms from baseline at Days 1 and 28 were similar between GLY and TIO. Post hoc analysis of the FEV1 AUC0-4h by time point on Day 1 showed significant improvements in patients receiving GLY versus TIO at 5 minutes (Δ=0.029 L, P=0.015), 15 minutes (Δ=0.033 L, P=0.026), and 1 hour (Δ=0.044 L, P=0.014). Safety results were comparable between both treatments. Conclusion The SPRING study demonstrates the superiority of GLY versus TIO in terms of superior bronchodilation in the first 4 hours after administration, thus extending the clinical data that support a faster onset of action of GLY versus TIO.
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Affiliation(s)
- Jose M Marin
- University Hospital Miguel Servet, IISAragón, CIBERES, Zaragoza, Spain
| | - Kai M Beeh
- Insaf Respiratory Research Institute, Wiesbaden, Germany
| | | | | | - Lennart Schaper
- Research Institute and Practice, Berlin-Brandenburg, Germany
| | - Dinesh Saralaya
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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182
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Singh D, Maleki-Yazdi MR, Tombs L, Iqbal A, Fahy WA, Naya I. Prevention of clinically important deteriorations in COPD with umeclidinium/vilanterol. Int J Chron Obstruct Pulmon Dis 2016; 11:1413-24. [PMID: 27445468 PMCID: PMC4928660 DOI: 10.2147/copd.s101612] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Minimizing the risk of disease progression and exacerbations is the key goal of COPD management, as these are well-established indicators of poor COPD prognosis. We developed a novel composite end point assessing three important aspects (lung function, health status, and exacerbations) of worsening in COPD. The objective was to determine whether dual bronchodilation with umeclidinium/vilanterol (UMEC/VI) reduces clinically important deteriorations (CIDs) in COPD versus placebo or bronchodilator monotherapy. Methods This study is a post hoc analysis of two 24-week trials comparing UMEC/VI 62.5/25 µg with UMEC 62.5 µg, VI 25 µg, or placebo (Study A; NCT01313650), or UMEC/VI 62.5/25 µg with tiotropium (TIO) 18 µg (Study B; NCT01777334) in patients with symptomatic COPD, without a history of frequent exacerbations. Deterioration was assessed as the time to a first CID, a composite measure defined as a decrease of ≥100 mL in trough forced expiratory volume in 1 second or ≥4-unit increase in St George’s Respiratory Questionnaire total score or an on-treatment moderate-to-severe COPD exacerbation. Results In Study A, fewer patients experienced a first CID with UMEC/VI (44%) versus UMEC (50%), VI (56%), and placebo (75%). The risk of a first CID was reduced with UMEC/VI (hazard ratio [HR]: 0.37 [95% confidence interval, CI: 0.30, 0.45]), UMEC (HR: 0.46 [95% CI: 0.38, 0.56]), and VI (HR: 0.55 [95% CI: 0.45, 0.66]; all P<0.001) versus placebo, and with UMEC/VI versus UMEC (HR: 0.80 [95% CI: 0.65, 0.97]; P<0.05) and versus VI (HR: 0.67 [95% CI: 0.55, 0.81]; P<0.001). In Study B, fewer patients experienced a first CID with UMEC/VI (41%) versus TIO (59%). UMEC/VI reduced the risk of a first composite CID by 43% versus TIO (HR: 0.57 [95% CI: 0.47, 0.69]; P<0.001). Conclusion This exploratory analysis, using a new assessment of clinical deterioration in COPD, revealed that a majority of symptomatic patients with low exacerbation risk experienced a deterioration during the 24-week study periods. UMEC/VI reduces the risk of a first CID versus placebo or bronchodilator monotherapy.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - M Reza Maleki-Yazdi
- Division of Respiratory Medicine, Women's College Hospital, University of Toronto, ON, Canada
| | | | - Ahmar Iqbal
- Respiratory Medical Franchise, GSK, Research Triangle Park, NC, USA
| | - William A Fahy
- Respiratory Medicines Development Centre, GSK, Stockley Park, Middlesex, UK
| | - Ian Naya
- Respiratory Medicines Development Centre, GSK, Stockley Park, Middlesex, UK
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183
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Yamauchi Y, Yasunaga H, Hasegawa W, Sakamoto Y, Takeshima H, Jo T, Matsui H, Fushimi K, Nagase T. Effect of outpatient therapy with inhaled corticosteroids on decreasing in-hospital mortality from pneumonia in patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:1403-11. [PMID: 27382276 PMCID: PMC4922764 DOI: 10.2147/copd.s107985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background and objectives Inhaled corticosteroids (ICS) and long-acting inhaled bronchodilators (IBD) are beneficial for the management of COPD. Although ICS has been reported to increase the risk of pneumonia in patients with COPD, it remains controversial whether it influences mortality. Using a Japanese national database, we examined the association between preadmission ICS therapy and in-hospital mortality from pneumonia in patients with COPD. Methods We retrospectively collected data from 1,165 hospitals in Japan on patients with COPD who received outpatient inhalation therapy and were admitted with pneumonia. Patients were categorized into those who received ICS with IBD and those who received IBD alone. We performed multivariate logistic regression analysis to examine the association between outpatient ICS therapy and in-hospital mortality, adjusting for the patients’ backgrounds. Results Of the 7,033 eligible patients, the IBD alone group (n=3,331) was more likely to be older, have lower body mass index, poorer general conditions, and more severe pneumonia than the ICS with IBD group (n=3,702). In-hospital mortality was 13.2% and 8.1% in the IBD alone and the ICS with IBD groups, respectively. After adjustment for patients’ backgrounds, the ICS with IBD group had significantly lower mortality than the IBD alone group (adjusted odds ratio, 0.80; 95% confidence interval, 0.68–0.94). Higher mortality was associated with older age, being male, lower body mass index, poorer general status, and more severe pneumonia. Conclusion Outpatient inhaled ICS and IBD therapy was significantly associated with lower mortality from pneumonia in patients with COPD than treatment with IBD alone.
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Affiliation(s)
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Wakae Hasegawa
- Department of Respiratory Medicine, Graduate School of Medicine
| | - Yukiyo Sakamoto
- Department of Respiratory Medicine, Graduate School of Medicine
| | | | - Taisuke Jo
- Department of Respiratory Medicine, Graduate School of Medicine; Division for Health Service Promotion, The University of Tokyo
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, Graduate School of Medicine
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184
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Watz H, Mailänder C, Baier M, Kirsten A. Effects of indacaterol/glycopyrronium (QVA149) on lung hyperinflation and physical activity in patients with moderate to severe COPD: a randomised, placebo-controlled, crossover study (The MOVE Study). BMC Pulm Med 2016; 16:95. [PMID: 27301417 PMCID: PMC4908762 DOI: 10.1186/s12890-016-0256-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physical activity limitation is common in chronic obstructive pulmonary disease (COPD), and is associated with worse health status, and increased hospitalisation and mortality. Long-acting bronchodilators, either alone or in combination, have been shown to improve exercise intolerance. However, none of these studies were designed with physical activity as primary outcome. This study assessed the effect of indacaterol/glycopyrronium fixed dose combination (IND/GLY) 110/50 μg once daily (OD) versus placebo on lung hyperinflation (inspiratory capacity [IC]) and physical activity in patients with moderate-to-severe COPD. METHODS In this multicentre, randomised, double-blind, placebo-controlled crossover study, patients received IND/GLY or placebo OD in two 21-day treatment periods (14-day washout between periods). Eligible patients were ≥40 years of age, current or ex-smokers (smoking history ≥10 pack-years), with post-salbutamol forced expiratory volume in 1 s (FEV1) 40-80 % predicted, and FEV1:forced vital capacity <0.70. The co-primary endpoints were peak IC after 21 days and average daily activity-related energy expenditure. Key secondary endpoints were average number of steps per day and the duration of at least moderate activity per day. Peak IC and FEV1 on Day 1, and trough IC and FEV1 after 21 days were other secondary endpoints. RESULTS A total of 194 patients were randomised (65.5 % male, mean age 62.8 years, mean FEV1 61.6 % predicted), with 183 (94.3 %) completing the study. Compared with placebo, IND/GLY significantly increased peak IC after 21 days (difference 202 mL, p < 0.0001), activity-related energy expenditure (difference 36.7 kcal/day, p = 0.040), and the average number of steps per day (difference 358, p = 0.029), with a trend towards an improvement in the duration of at least moderate activity (difference 4.4 min, p = 0.264). IND/GLY was associated with statistically significant improvements versus placebo in peak IC and FEV1 on Day 1, and trough IC and FEV1 after 21 days. The incidence of treatment-emergent adverse events was 22.8 % with IND/GLY and 22.9 % with placebo. CONCLUSIONS In this study, compared with placebo, IND/GLY reduced hyperinflation, and, despite no patient education or lifestyle advice, improved daily physical activity levels. This suggests that IND/GLY has the potential to impact two of the main clinical concerns in the care of patients with COPD. TRIAL REGISTRATION ClinicalTrials.gov number: NCT01996319 .
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Affiliation(s)
- Henrik Watz
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Member of the German Center for Lung Research, Woehrendamm 80, D-22927, Grosshansdorf, Germany.
| | | | | | - Anne Kirsten
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Member of the German Center for Lung Research, Woehrendamm 80, D-22927, Grosshansdorf, Germany
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185
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Cazzola M, Calzetta L, Puxeddu E, Ora J, Facciolo F, Rogliani P, Matera MG. Pharmacological characterisation of the interaction between glycopyrronium bromide and indacaterol fumarate in human isolated bronchi, small airways and bronchial epithelial cells. Respir Res 2016; 17:70. [PMID: 27296533 PMCID: PMC4906998 DOI: 10.1186/s12931-016-0386-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nowadays, there is a considerable gap in knowledge concerning the mechanism(s) by which long-acting β2-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) interact to induce bronchodilation. This study aimed to characterise the pharmacological interaction between glycopyrronium bromide and indacaterol fumarate and to identify the mechanism(s) leading to the bronchorelaxant effect of this interaction. METHODS The effects of glycopyrronium plus indacaterol on the contractile tone of medium and small human isolated bronchi were evaluated, and acetylcholine and cAMP concentrations were quantified. The interaction was assessed by Bliss Independence approach. RESULTS Glycopyrronium plus indacaterol synergistically inhibited the bronchial tone (medium bronchi, +32.51 % ± 7.86 %; small bronchi, +28.46 % ± 5.35 %; P < 0.05 vs. additive effect). The maximal effect was reached 140 min post-administration. A significant (P < 0.05) synergistic effect was observed during 9 h post-administration on the cholinergic tone, but not on the histaminergic contractility. Co-administration of glycopyrronium and indacaterol reduced the release of acetylcholine from the epithelium but not from bronchi, and enhanced cAMP levels in bronchi and epithelial cells (P < 0.05 vs. control), an effect that was inhibited by the selective KCa(++) channel blocker iberiotoxin. The role of cAMP-dependent pathway was confirmed by the synergistic effect elicited by the adenylate cyclase activator forskolin on glycopyrronium (P < 0.05 vs. additive effect), but not on indacaterol (P > 0.05 vs. additive effect), with regard of the bronchial relaxant response and cAMP increase. CONCLUSIONS Glycopyrronium/indacaterol co-administration leads to a synergistic improvement of bronchodilation by increasing cAMP concentrations in both airway smooth muscle and bronchial epithelium, and by decreasing acetylcholine release from the epithelium.
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Affiliation(s)
- Mario Cazzola
- Department of Systems Medicine, Chair of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy.,Department of Systems Medicine, Respiratory Pharmacology Research Unit, University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy.,Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Luigino Calzetta
- Department of Systems Medicine, Respiratory Pharmacology Research Unit, University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy.
| | - Ermanno Puxeddu
- Department of Systems Medicine, Chair of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy.,Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Francesco Facciolo
- Regina Elena National Cancer Institute, Thoracic Surgery Unit, Rome, Italy
| | - Paola Rogliani
- Department of Systems Medicine, Chair of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy.,Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Maria Gabriella Matera
- Department of Experimental Medicine, Unit of Pharmacology, Second University of Naples, Naples, Italy
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186
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Wedzicha JA, Banerji D, Chapman KR, Vestbo J, Roche N, Ayers RT, Thach C, Fogel R, Patalano F, Vogelmeier CF. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med 2016; 374:2222-34. [PMID: 27181606 DOI: 10.1056/nejmoa1516385] [Citation(s) in RCA: 561] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most guidelines recommend either a long-acting beta-agonist (LABA) plus an inhaled glucocorticoid or a long-acting muscarinic antagonist (LAMA) as the first-choice treatment for patients with chronic obstructive pulmonary disease (COPD) who have a high risk of exacerbations. The role of treatment with a LABA-LAMA regimen in these patients is unclear. METHODS We conducted a 52-week, randomized, double-blind, double-dummy, noninferiority trial. Patients who had COPD with a history of at least one exacerbation during the previous year were randomly assigned to receive, by inhalation, either the LABA indacaterol (110 μg) plus the LAMA glycopyrronium (50 μg) once daily or the LABA salmeterol (50 μg) plus the inhaled glucocorticoid fluticasone (500 μg) twice daily. The primary outcome was the annual rate of all COPD exacerbations. RESULTS A total of 1680 patients were assigned to the indacaterol-glycopyrronium group, and 1682 to the salmeterol-fluticasone group. Indacaterol-glycopyrronium showed not only noninferiority but also superiority to salmeterol-fluticasone in reducing the annual rate of all COPD exacerbations; the rate was 11% lower in the indacaterol-glycopyrronium group than in the salmeterol-fluticasone group (3.59 vs. 4.03; rate ratio, 0.89; 95% confidence interval [CI], 0.83 to 0.96; P=0.003). The indacaterol-glycopyrronium group had a longer time to the first exacerbation than did the salmeterol-fluticasone group (71 days [95% CI, 60 to 82] vs. 51 days [95% CI, 46 to 57]; hazard ratio, 0.84 [95% CI, 0.78 to 0.91], representing a 16% lower risk; P<0.001). The annual rate of moderate or severe exacerbations was lower in the indacaterol-glycopyrronium group than in the salmeterol-fluticasone group (0.98 vs. 1.19; rate ratio, 0.83; 95% CI, 0.75 to 0.91; P<0.001), and the time to the first moderate or severe exacerbation was longer in the indacaterol-glycopyrronium group than in the salmeterol-fluticasone group (hazard ratio, 0.78; 95% CI, 0.70 to 0.86; P<0.001), as was the time to the first severe exacerbation (hazard ratio, 0.81; 95% CI, 0.66 to 1.00; P=0.046). The effect of indacaterol-glycopyrronium versus salmeterol-fluticasone on the rate of COPD exacerbations was independent of the baseline blood eosinophil count. The incidence of adverse events and deaths was similar in the two groups. The incidence of pneumonia was 3.2% in the indacaterol-glycopyrronium group and 4.8% in the salmeterol-fluticasone group (P=0.02). CONCLUSIONS Indacaterol-glycopyrronium was more effective than salmeterol-fluticasone in preventing COPD exacerbations in patients with a history of exacerbation during the previous year. (Funded by Novartis; FLAME ClinicalTrials.gov number, NCT01782326.).
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Affiliation(s)
- Jadwiga A Wedzicha
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Donald Banerji
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Kenneth R Chapman
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Jørgen Vestbo
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Nicolas Roche
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - R Timothy Ayers
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Chau Thach
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Robert Fogel
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Francesco Patalano
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
| | - Claus F Vogelmeier
- From the National Heart and Lung Institute, Imperial College London, London (J.A.W.), and the Centre for Respiratory Medicine and Allergy, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester (J.V.) - all in the United Kingdom; Novartis Pharmaceuticals, East Hanover, NJ (D.B., R.T.A., C.T., R.F.); Asthma and Airway Centre, University Health Network and University of Toronto, Toronto (K.R.C.); Service de Pneumologie Assistance Publique-Hôpitaux de Paris, University Paris Descartes (EA2511), Paris (N.R.); Novartis Pharma AG, Basel, Switzerland (F.P.); and the Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany (C.F.V.)
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Mahler DA, Gifford AH, Satti A, Jessop N, Eckert JH, D'Andrea P, Mota F, Banerjee R. Long-term safety of glycopyrrolate: A randomized study in patients with moderate-to-severe COPD (GEM3). Respir Med 2016; 115:39-45. [DOI: 10.1016/j.rmed.2016.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/09/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
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Siler TM, Donald AC, O’Dell D, Church A, Fahy WA. A randomized, parallel-group study to evaluate the efficacy of umeclidinium/vilanterol 62.5/25 μg on health-related quality of life in patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:971-9. [PMID: 27274218 PMCID: PMC4869636 DOI: 10.2147/copd.s102962] [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 combination of the inhaled muscarinic antagonist umeclidinium (UMEC) with the long-acting β2-agonist vilanterol (VI) has been shown to provide significant improvements in lung function compared with UMEC, VI, or placebo (PBO) in patients with chronic obstructive pulmonary disease (COPD). This study was specifically designed to support these findings by assessing health-related quality of life and symptomatic outcomes in a similar population. METHODS This was a 12-week multicenter, randomized, double-blind, parallel-group, placebo-controlled study. Eligible patients were randomized 1:1 to receive once-daily UMEC/VI 62.5/25 μg (via ELLIPTA(®) dry powder inhaler) or PBO for 12 weeks. The primary endpoint was St George's Respiratory Questionnaire (SGRQ) total score at day 84. Secondary efficacy endpoints included rescue albuterol use (puffs/day) over weeks 1-12 and trough forced expiratory volume in 1 second on day 84. Adverse events were also assessed. RESULTS A total of 496 patients were included in the intent-to-treat population in the UMEC/VI (n=248) and PBO (n=248) treatment groups. UMEC/VI 62.5/25 μg provided a significant and clinically meaningful improvement in SGRQ total score at day 84 versus PBO (difference between treatments in SGRQ total score change from baseline: -4.03 [95% confidence interval {CI}: -6.28, -1.79]; P<0.001). UMEC/VI 62.5/25 μg resulted in a statistically significant reduction in rescue albuterol use versus PBO (-0.7 puffs/day [95% CI: -1.1, -0.4]; P<0.001). UMEC/VI 62.5/25 μg provided a significant and clinically meaningful improvement in trough forced expiratory volume in 1 second on day 84 versus PBO (122 mL [95% CI: 71, 172]; P<0.001). The incidence of adverse events was similar between treatments (32% and 30% of patients in the UMEC/VI 62.5/25 μg and PBO groups, respectively). CONCLUSION The results of this study demonstrate that treatment with UMEC/VI 62.5/25 μg provides clinically important improvements in SGRQ and rescue medication use versus PBO in patients with moderate-to-very-severe COPD.
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Affiliation(s)
| | | | - Dianne O’Dell
- GSK, Research Triangle Park, NC, USA
- Pearl Therapeutics, Inc., Durham, NC, USA
| | | | - William A Fahy
- GSK, Respiratory Medicines Development Centre, Stockley Park, Middlesex, UK
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Mahler DA, Kerwin E, Ayers T, FowlerTaylor A, Maitra S, Thach C, Lloyd M, Patalano F, Banerji D. FLIGHT1 and FLIGHT2: Efficacy and Safety of QVA149 (Indacaterol/Glycopyrrolate) versus Its Monocomponents and Placebo in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2016; 192:1068-79. [PMID: 26177074 DOI: 10.1164/rccm.201505-1048oc] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Current Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy recommends the combination of two long-acting bronchodilators of different pharmacologic classes for the management of chronic obstructive pulmonary disease (COPD) if symptoms are not adequately controlled by a single bronchodilator. OBJECTIVES The FLIGHT1 and FLIGHT2 studies evaluated the efficacy and safety of QVA149 (indacaterol/glycopyrrolate), a fixed-dose combination of a long-acting β2-agonist (indacaterol) and a long-acting muscarinic antagonist (glycopyrrolate), compared with its monocomponents and placebo in patients with moderate-to-severe COPD. METHODS FLIGHT1 and FLIGHT2 were 12-week, identical, multicenter, randomized, double-blind, parallel-group, placebo- and active-controlled studies. Patients were randomized (1:1:1:1) to indacaterol/glycopyrrolate (27.5/15.6 μg twice daily), indacaterol (27.5 μg twice daily), glycopyrrolate (15.6 μg twice daily), or placebo, all delivered via the Neohaler device. The primary objective was to demonstrate the superiority of indacaterol/glycopyrrolate versus its monocomponents for standardized area under the curve from 0-12 hours for FEV1 at Week 12. Secondary objectives included St. George's Respiratory Questionnaire total score and transition dyspnea index total score and reduction in daily rescue medication use with indacaterol/glycopyrrolate versus placebo. MEASUREMENTS AND MAIN RESULTS In total, 2,038 patients were included in the pooled analysis. Indacaterol/glycopyrrolate was statistically superior in terms of FEV1 area under the curve from 0-12 hours compared with its monocomponents (P < 0.001). Statistically and clinically meaningful improvements in St. George's Respiratory Questionnaire total score, transition dyspnea index total score, and reduction in rescue medication use were observed with indacaterol/glycopyrrolate compared with placebo (P < 0.001). The safety profile was comparable across the treatment groups. CONCLUSIONS Indacaterol/glycopyrrolate twice daily can be an alternative treatment option for the management of symptomatic patients with moderate-to-severe COPD. Clinical trial registered with www.clinicaltrials.gov (NCT 01727141 and NCT 0171251).
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Affiliation(s)
- Donald A Mahler
- 1 Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,2 Valley Regional Hospital, Claremont, New Hampshire
| | - Edward Kerwin
- 3 Clinical Research Institute of Southern Oregon, Medford, Oregon
| | - Tim Ayers
- 4 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | - Chau Thach
- 4 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Mark Lloyd
- 4 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Donald Banerji
- 4 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
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190
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Calzetta L, Rogliani P, Matera MG, Cazzola M. A Systematic Review With Meta-Analysis of Dual Bronchodilation With LAMA/LABA for the Treatment of Stable COPD. Chest 2016; 149:1181-96. [DOI: 10.1016/j.chest.2016.02.646] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Kostikas K, Siafakas NM. Does the Term "Deflators" Reflect More Accurately the Beneficial Effects of Long-acting Bronchodilators in COPD? COPD 2016; 13:537-9. [PMID: 27115572 DOI: 10.3109/15412555.2016.1153615] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Konstantinos Kostikas
- a Department of 2nd Respiratory Medicine Department , University of Athens Medical School , Athens , Greece.,b Novartis Pharma AG , Basel , Switzerland
| | - Nikolaos M Siafakas
- c Professor Emeritus of Thoracic Medicine , University of Crete Medical School , Heraklion , Greece
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Cohen JS, Miles MC, Donohue JF, Ohar JA. Dual therapy strategies for COPD: the scientific rationale for LAMA + LABA. Int J Chron Obstruct Pulmon Dis 2016; 11:785-97. [PMID: 27143870 PMCID: PMC4841398 DOI: 10.2147/copd.s54513] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity, mortality, and health care expenditure worldwide. Relaxation of airway smooth muscle with inhaled bronchodilators is the cornerstone of treatment for stable COPD, with inhaled corticosteroids reserved for those with a history of exacerbations. Tiotropium has occupied center stage in COPD treatment for over 10 years and improves lung function, quality of life, exercise endurance, and reduces the risk of COPD exacerbation. Long-acting β2-agonists (LABAs) improve lung function, reduce dynamic hyperinflation, increase exercise tolerance, health-related quality of life, and reduce acute exacerbation of COPD. The combination of long-acting muscarinic antagonists (LAMAs) and LABAs is thought to leverage different pathways to induce bronchodilation using submaximal drug doses, increasing the benefits and minimizing receptor-specific side effects. Umeclidinium/vilanterol is the first combination of LAMA/LABA to be approved for use in stable COPD in USA and Europe. Additionally, indacaterol/glycopyrronium and aclidinium/formoterol have been approved in Europe and in numerous locations outside USA. Several other agents are in the late stages of development, most of which offer once-daily dosing. The benefits of new LAMA/LABA combinations include improved pulmonary function, dyspnea, and health-related quality of life, and in some cases, reduced exacerbations. These evolving treatments will provide new opportunities and challenges in the management of COPD.
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Affiliation(s)
| | - Matthew C Miles
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - James F Donohue
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Jill A Ohar
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Schlueter M, Gonzalez-Rojas N, Baldwin M, Groenke L, Voss F, Reason T. Comparative efficacy of fixed-dose combinations of long-acting muscarinic antagonists and long-acting β2-agonists: a systematic review and network meta-analysis. Ther Adv Respir Dis 2016; 10:89-104. [PMID: 26746383 PMCID: PMC5933564 DOI: 10.1177/1753465815624612] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A number of long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) fixed-dose combinations (FDCs) for treatment of moderate-to-very severe chronic obstructive pulmonary disease (COPD) have recently become available, but none have been directly compared in head-to-head randomized controlled trials (RCTs). The purpose of this study was to assess the relative clinical benefit of all currently available LAMA/LABA FDCs using a Bayesian network meta-analysis (NMA). METHODS A systematic literature review identified RCTs investigating the efficacy, safety and quality of life associated with licensed LAMA/LABA FDCs for the treatment of moderate-to-very severe COPD. RCTs were screened for inclusion in the NMA using prespecified eligibility criteria. Data were extracted for outcomes of interest, including change in trough forced expiratory volume in 1 second (tFEV1) from baseline, St. George Respiratory Questionnaire (SGRQ) percentage of responders, Transition Dyspnea Index (TDI) percentage of responders, change in SGRQ score from baseline, change in TDI focal score from baseline, moderate-to-severe exacerbations, all-cause discontinuation, and discontinuation due to adverse events. RESULTS Following screening, a total of 27 trials from 26 publications with 30,361 subjects were eligible for inclusion in the NMA. Nonsignificant results were seen in most analyses comparing efficacy, exacerbations and discontinuation rates of included LAMA/LABA FDCs (i.e. aclidinium/formoterol 400/12 µg, glycopyrronium/indacaterol 110/50 µg, tiotropium + olodaterol 5/5 µg, umeclidinium/vilanterol 62.5/25 µg). Meta-regression controlling for post-bronchodilator percentage of tFEV1 predicted at baseline as well as meta-regression adjusting for concomitant use of inhaled corticosteroids at baseline was performed to assess the magnitude of effect modification and produced similar results as observed in the base case analysis. CONCLUSION All LAMA/LABA FDCs were found to have similar efficacy and safety. Definitive assessment of the relative efficacy of different treatments can only be performed through direct comparison in head-to-head RCTs. In the absence of such data, this indirect comparison may be of value in clinical and health economic decision-making.
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Affiliation(s)
| | | | | | - Lars Groenke
- Boehringer Ingelheim GmbH, Ingelheim am Rhein, Germany
| | - Florian Voss
- Boehringer Ingelheim GmbH, Ingelheim am Rhein, Germany
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Guimarães M, Bugalho A, Oliveira AS, Moita J, Marques A. COPD control: Can a consensus be found? REVISTA PORTUGUESA DE PNEUMOLOGIA 2016; 22:167-76. [PMID: 27004479 DOI: 10.1016/j.rppnen.2016.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 12/18/2015] [Accepted: 01/05/2016] [Indexed: 11/24/2022] Open
Abstract
There are currently no reliable instruments for assessing the onset and progression of chronic obstructive pulmonary disease (COPD) or predicting its prognosis. Currently, a comprehensive assessment of COPD including several objective and subjective parameters is recommended. However, the lack of biomarkers precludes a correct assessment of COPD severity, which consequently hampers adequate therapeutic approaches and COPD control. In the absence of a definition of "well-controlled disease", a consensus regarding COPD control will be difficult to reach. However, COPD patient assessment should be multidimensional, and anchored in five points: control of symptoms, decline of pulmonary function, levels of physical activity, exacerbations, and Quality of Life. Several non-pharmacological and pharmacological measures are currently available to achieve disease control. Smoking cessation, vaccination, exercise training programs and pulmonary rehabilitation are recognized as important non-pharmacological measures but bronchodilators are the pivotal therapy in the control of COPD. This paper discusses several objective and subjective parameters that may bridge the gap between disease assessment and disease control. The authors conclude that, at present, it is not possible to reach a consensus regarding COPD control, essentially due to the lack of objective instruments to measure it. Some recommendations are set forth, but true COPD control awaits further objective assessments.
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Affiliation(s)
- M Guimarães
- Pulmonology Department, Centro Hospitalar Gaia-Espinho, EPE, Portugal.
| | - A Bugalho
- Pulmonology Department, Hospital CUF Infante Santo/Hospital CUF Descobertas, Lisbon, Portugal; Chronic Diseases Research Center (CEDOC), Lisbon School of Medical Sciences, Nova University, Lisbon, Portugal.
| | - A S Oliveira
- Pulmonology Department, Hospital Pulido Valente, CHLN, Lisbon, Portugal.
| | - J Moita
- General Hospital, Coimbra University Hospital Center, Portugal.
| | - A Marques
- Pulmonology Department, São João Hospital Center, Oporto Medical School, Porto, Portugal.
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Abstract
Chronic obstructive pulmonary disease (COPD) is a major cause of death and disability worldwide. Inhaled bronchodilators are the mainstay of COPD pharmacological treatment. Long-acting muscarinic antagonists (LAMAs) are a major class of inhaled bronchodilators. Some LAMA/device systems with different characteristics and dosing schedules are currently approved for maintenance therapy of COPD and a range of other products are being developed. They improve lung function and patient-reported outcomes and reduce acute bronchial exacerbations with good safety. LAMAs are used either alone or associated with long-acting β₂-agonists, eventually in fixed dose combinations. Long-acting β₂-agonist/LAMA combinations assure additional benefits over the individual components alone. The reader will obtain a view of the safety and efficacy of the different LAMA/device systems in COPD patients.
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Affiliation(s)
- Andrea S Melani
- Dipartimento Vasi, Cuore e Torace, Fisiopatologia e Riabilitazione Respiratoria, Policlinico Le Scotte, Azienda Ospedaliera Universitaria Senese, Viale Bracci Siena, Italy
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de la Loge C, Tugaut B, Fofana F, Lambert J, Hennig M, Tschiesner U, Vahdati-Bolouri M, Segun Ismaila A, Suresh Punekar Y. Relationship Between FEV 1 and Patient-Reported Outcomes Changes: Results of a Meta-Analysis of Randomized Trials in Stable COPD. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 3:519-538. [PMID: 28848877 DOI: 10.15326/jcopdf.3.2.2015.0152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: This meta-analysis assessed the relationship between change from baseline (CFB) in spirometric measurements (trough forced expiratory volume in 1 second [FEV1] and FEV1 area under the curve [AUC]) and patient-reported outcomes (St. George's Respiratory Questionnaire total score [SGRQ] CFB, Transition Dyspnea Index [TDI] and exacerbation rates) after 6-12 months' follow-up, using study treatment-group level data. Methods: A systematic literature search was performed for randomized controlled trials of ≥24 weeks duration in adults with chronic obstructive pulmonary disease (COPD). Studies reporting ≥1 spirometric measurement and ≥1 patient-reported outcome (PRO) at baseline and at study endpoint were selected. The relationships between PROs and spirometric endpoints were assessed using Pearson correlation coefficient and meta-regression. Results: Fifty-two studies (62,385 patients) were included. Primary weighted analysis conducted at the last assessment showed a large significant negative correlation (r, -0.68 [95% confidence interval (CI); -0.77, -0.57]) between trough FEV1 and SGRQ. Improvement of 100 mL in trough FEV1 corresponded to a 5.9 point reduction in SGRQ. Similarly, a reduction of 4 points on SGRQ corresponded to 40 mL improvement in trough FEV1 (p<0.001). The weighted correlation coefficients of trough FEV1 with TDI, exacerbation rate (all) and exacerbation rate (moderate/severe) at last assessment point were 0.57, -0.69 and -0.57, respectively (all p<0.05). For the analyses excluding placebo groups, the correlations of FEV1 with SGRQ and TDI were lower but significant. Conclusions: A strong association exists between changes in spirometric measurements and changes in PROs.
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Affiliation(s)
| | | | | | | | - Michael Hennig
- Biostatistics and Epidemiology, GlaxoSmithKline, Munich, Germany
| | | | - Mitra Vahdati-Bolouri
- Research and Development, Global Respiratory Franchise, GlaxoSmithKline, Brentford, United Kingdom
| | - Afisi Segun Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline Research and Development, Research Triangle Park, North Carolina; Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Donohue JF, Singh D, Munzu C, Kilbride S, Church A. Magnitude of umeclidinium/vilanterol lung function effect depends on monotherapy responses: Results from two randomised controlled trials. Respir Med 2016; 112:65-74. [DOI: 10.1016/j.rmed.2016.01.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 01/01/2016] [Indexed: 10/22/2022]
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198
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Medic G, Lindner L, van der Weijden M, Karabis A. Efficacy and Safety of Aclidinium/Formoterol versus Tiotropium in COPD: Results of an Indirect Treatment Comparison. Adv Ther 2016; 33:379-99. [PMID: 26883661 PMCID: PMC4833795 DOI: 10.1007/s12325-016-0299-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The objective of this study was to estimate the relative efficacy and safety of fixed-dose combination aclidinium/formoterol 400/12 μg twice daily compared to tiotropium 18 μg once daily in adult patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). METHODS A systematic literature review performed in March 2014, using a predefined search strategy in MEDLINE, EMBASE and Cochrane Library, identified 17 randomized placebo-controlled trials, (tiotropium n = 15; aclidinium/formoterol n = 2). Outcomes of interest were: bronchodilation (peak and trough forced expiratory volume in 1 s (FEV1)), COPD symptoms [Transition Dyspnea Index (TDI) focal score and % of responders (>1 unit improvement)] and Health Related Quality of Life (HRQoL) [St. George's Respiratory Questionnaire (SGRQ) total score and % responders (>4 unit improvement)], % of patients with ≥1 exacerbations, adverse events (AE), serious adverse events (SAE), hospitalization and mortality, all at 24 weeks. In the absence of head-to-head trials between aclidinium/formoterol and tiotropium, a Bayesian indirect treatment comparison (ITC) was used with placebo as common control. RESULTS Regarding bronchodilation, aclidinium/formoterol was found to be more efficacious than tiotropium at peak FEV1, with mean difference in change from baseline (DCFB) 143 mL [95% credible interval (CrI): 112, 174] and at trough FEV1 [DCFB 26 mL (95% CrI -2, 55)]. Aclidinium/formoterol is expected to be more efficacious than tiotropium in improving dyspnea symptoms measured by TDI [DCFB 0.54 points (95% CrI 0.09, 0.99); odds ratio (OR) of responders 1.51 (95% CrI 1.11, 2.06)]. SGRQ results are comparable for aclidinium/formoterol versus tiotropium [DCFB -0.52 (95% CrI -2.21, 1.17); OR of responders 1.16 (95% CrI 0.47, 2.87)]. The ITC results suggest similar safety profiles regarding AEs, SAEs and hospitalization. CONCLUSION Based on the ITC, aclidinium/formoterol is expected to be more efficacious than tiotropium in terms of lung function and symptom control while providing comparable HRQoL results and safety profile. FUNDING AstraZeneca.
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Affiliation(s)
- Goran Medic
- Real World Strategy and Analytics, Mapi Group, Houten, The Netherlands
| | | | | | - Andreas Karabis
- Real World Strategy and Analytics, Mapi Group, Houten, The Netherlands
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199
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Costs of Tiotropium Bromide Delivered via the Respimat® Inhaler in COPD Patients in Italy. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2016. [DOI: 10.5301/grhta.5000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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200
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Ferreira AJ, Reis A, Marçal N, Pinto P, Bárbara C. COPD: A stepwise or a hit hard approach? REVISTA PORTUGUESA DE PNEUMOLOGIA 2016; 22:214-21. [PMID: 26935750 DOI: 10.1016/j.rppnen.2015.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 11/28/2015] [Accepted: 12/27/2015] [Indexed: 10/22/2022] Open
Abstract
Current guidelines differ slightly on the recommendations for treatment of Chronic Obstructive Pulmonary Disease (COPD) patients, and although there are some undisputed recommendations, there is still debate regarding the management of COPD. One of the hindrances to deciding which therapeutic approach to choose is late diagnosis or misdiagnosis of COPD. After a proper diagnosis is achieved and severity assessed, the choice between a stepwise or "hit hard" approach has to be made. For GOLD A patients the stepwise approach is recommended, whilst for B, C and D patients this remains debatable. Moreover, in patients for whom inhaled corticosteroids (ICS) are recommended, a step-up or "hit hard" approach with triple therapy will depend on the patient's characteristics and, for patients who are being over-treated with ICS, ICS withdrawal should be performed, in order to optimize therapy and reduce excessive medications. This paper discusses and proposes stepwise, "hit hard", step-up and ICS withdrawal therapeutic approaches for COPD patients based on their GOLD group. We conclude that all approaches have benefits, and only a careful patient selection will determine which approach is better, and which patients will benefit the most from each approach.
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Affiliation(s)
- A J Ferreira
- Pulmonology Department, Centro Hospitalar Universitário de Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Portugal
| | - A Reis
- Pulmonology Department, Centro Hospitalar Tondela-Viseu, EPE, Portugal
| | - N Marçal
- Pulmonology Department, Hospital de Vila Franca de Xira, Portugal
| | - P Pinto
- Chest Department, Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Environmental Health Institute (ISAMB), Faculty of Medicine, University of Lisbon, Portugal
| | - C Bárbara
- Chest Department, Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Environmental Health Institute (ISAMB), Faculty of Medicine, University of Lisbon, Portugal.
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