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Anzueto A, Barjaktarevic IZ, Siler TM, Rheault T, Bengtsson T, Rickard K, Sciurba F. Ensifentrine, a Novel Phosphodiesterase 3 and 4 Inhibitor for the Treatment of Chronic Obstructive Pulmonary Disease: Randomized, Double-Blind, Placebo-controlled, Multicenter Phase III Trials (the ENHANCE Trials). Am J Respir Crit Care Med 2023; 208:406-416. [PMID: 37364283 PMCID: PMC10449067 DOI: 10.1164/rccm.202306-0944oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 06/28/2023] Open
Abstract
Rationale: Ensifentrine is a novel, selective, dual phosphodiesterase (PDE)3 and PDE4 inhibitor with bronchodilator and antiinflammatory effects. Replicate phase III trials of nebulized ensifentrine were conducted (ENHANCE-1 and ENHANCE-2) to assess these effects in patients with chronic obstructive pulmonary disease (COPD). Objectives: To evaluate the efficacy of ensifentrine compared with placebo for lung function, symptoms, quality of life, and exacerbations in patients with COPD. Methods: These phase III, multicenter, randomized, double-blind, parallel-group, placebo-controlled trials were conducted between September 2020 and December 2022 at 250 research centers and pulmonology practices in 17 countries. Patients aged 40-80 years with moderate to severe symptomatic COPD were enrolled. Measurements and Main Results: Totals of 760 (ENHANCE-1) and 789 (ENHANCE-2) patients were randomized and treated, with 69% and 55% receiving concomitant long-acting muscarinic antagonists or long-acting β2-agonists, respectively. Post-bronchodilator FEV1 percentage predicted values were 52% and 51% of predicted normal. Ensifentrine treatment significantly improved average FEV1 area under the curve at 0-12 hours versus placebo (ENHANCE-1, 87 ml [95% confidence interval, 55, 119]; ENHANCE-2, 94 ml [65, 124]; both P < 0.001). Ensifentrine treatment significantly improved symptoms (Evaluating Respiratory Symptoms) and quality of life (St. George's Respiratory Questionnaire) versus placebo at Week 24 in ENHANCE-1 but not in ENHANCE-2. Ensifentrine treatment reduced the rate of moderate or severe exacerbations versus placebo over 24 weeks (ENHANCE-1, rate ratio, 0.64 [0.40, 1.00]; P = 0.050; ENHANCE-2, rate ratio, 0.57 [0.38, 0.87]; P = 0.009) and increased time to first exacerbation (ENHANCE-1, hazard ratio, 0.62 [0.39, 0.97]; P = 0.038; ENHANCE-2, hazard ratio, 0.58 [0.38, 0.87]; P = 0.009). Adverse event rates were similar to those for placebo. Conclusions: Ensifentrine significantly improved lung function in both trials, with results supporting exacerbation rate and risk reduction in a broad COPD population and in addition to other classes of maintenance therapies. Clinical trial registered with www. CLINICALTRIALS gov and EudraCT (ENHANCE-1, www. CLINICALTRIALS gov identifier NCT04535986, EudraCT identifier 2020-002086-34; ENHANCE-2, www. CLINICALTRIALS gov identifier NCT04542057, EudraCT identifier 2020-002069-32).
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Affiliation(s)
- Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, Texas
- University of Texas Health, San Antonio, Texas
| | - Igor Z. Barjaktarevic
- Division of Pulmonary and Critical Care, University of California, Los Angeles, Los Angeles, California
| | | | | | | | | | - Frank Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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2
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Matera MG, Hanania NA, Maniscalco M, Cazzola M. Pharmacotherapies in Older Adults with COPD: Challenges and Opportunities. Drugs Aging 2023:10.1007/s40266-023-01038-0. [PMID: 37316689 DOI: 10.1007/s40266-023-01038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/16/2023]
Abstract
Older adults have a higher prevalence of chronic obstructive pulmonary disease (COPD), which will likely increase substantially in the coming decades owing to aging populations and increased long-term exposure to risk factors for this disease. COPD in older adults is characterized by low-grade chronic systemic inflammation, known as inflamm-aging. It contributes substantially to age-associated pulmonary changes that are clinically expressed by reduced lung function, poor health status, and limitations in activities of daily living. In addition, inflamm-aging has been associated with the onset of many comorbidities commonly encountered in COPD. Furthermore, physiologic changes that are often seen with aging can influence the optimal treatment of older patients with COPD. Therefore, variables such as pharmacokinetics, pharmacodynamics, polypharmacy, comorbidities, adverse drug responses, drug interactions, method of administration, and social and economic issues that impact nutrition and adherence to therapy must be carefully evaluated when prescribing medication to these patients because each of them alone or together may affect the outcome of treatment. Current COPD medications focus mainly on alleviating COPD-related symptoms, so alternative treatment approaches that target the disease progression are being investigated. Considering the importance of inflamm-aging, new anti-inflammatory molecules are being evaluated, focusing on inhibiting the recruitment and activation of inflammatory cells, blocking mediators of inflammation thought to be important in the recruitment or activation of these inflammatory cells or released by these cells. Potential therapies that may slow the aging processes by acting on cellular senescence, blocking the processes that cause it (senostatics), eliminating senescent cells (senolytics), or targeting the ongoing oxidative stress seen with aging need to be evaluated.
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Affiliation(s)
- Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mauro Maniscalco
- Pulmonary Rehabilitation Unit of Telese Terme Institute, Istituti Clinici Scientifici Maugeri IRCCS, Telese Terme, Italy
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome 'Tor Vergata', Via Montpellier 1, 00133, Rome, Italy.
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McCarthy C, Flood M, Clyne B, Smith SM, Wallace E, Boland F, Moriarty F. Medication changes and potentially inappropriate prescribing in older patients with significant polypharmacy. Int J Clin Pharm 2023; 45:191-200. [PMID: 36385206 DOI: 10.1007/s11096-022-01497-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/01/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Number of medicines and medicines appropriateness are often used as outcome measures to evaluate the effectiveness of deprescribing interventions. AIM The aim of this study was to evaluate changes in prescribing, potentially inappropriate prescriptions (PIP) and prescribing of low-value medicines in older people with multimorbidity and significant polypharmacy. METHOD This study was a retrospective secondary analysis of prescription data from a cluster randomised controlled trial involving 404 participants aged ≥ 65 years and prescribed ≥ 15 repeat medicines from 51 different general practices. For this study, repeat medications at baseline and follow-up (~ 1 year later) were assigned Anatomical Therapeutic Classification (ATC) codes. Outcomes were the most commonly prescribed and potentially inappropriately prescribed drug groups, the most frequently discontinued or initiated drug groups and the number of changes per person between baseline and follow-up. RESULTS There were 7051 medicines prescribed to 404 participants at baseline. There was a median of 17 medicines (IQR 15-19) at baseline and 16 (IQR 14-19) at follow-up. PIP represented 17.1% of prescriptions at baseline and 15.7% (n = 6777) at follow-up. There were reductions in the prescription of most drug groups with the largest reduction in antiplatelet prescriptions. Considering medication discontinuations, initiations and switches, there was a median of five medication changes per person (range 0-30, IQR 3-9) by follow-up. There were 95 low-value prescriptions at baseline reducing to 78 at follow-up. CONCLUSION The number of medication changes per person was not reflected by summarising medication count at two time points, highlighting the complexity of prescribing for patients with polypharmacy. Frequent medication changes has potentially important implications for patients in terms of adherence and medication safety. TRIAL REGISTRY The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).
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Affiliation(s)
- Caroline McCarthy
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,Data Science Centre, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
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Tanimura K, Sato S, Fujita Y, Yamamoto Y, Hajiro T, Horita N, Kawayama T, Muro S. The efficacy and safety of additional treatment with short-acting muscarinic antagonist combined with long-acting beta-2 agonist in stable patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Chron Respir Dis 2023; 20:14799731231166008. [PMID: 36967224 PMCID: PMC10052583 DOI: 10.1177/14799731231166008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The rationale for additional treatment with short-acting bronchodilators combined with long-acting bronchodilators for patients with chronic obstructive pulmonary disease (COPD) is not adequately studied. METHODS We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of a short-acting muscarinic antagonist (SAMA) therapy combined with a long-acting beta-2 agonist (LABA) in patients with stable COPD. Pulmonary function, dyspnea, health-related quality of life, exercise tolerance, physical activity, exacerbations of COPD, and adverse events during regular use were set as outcomes of interest. RESULTS We included five controlled trials including two sets of publicly available online data without article publications for the meta-analysis. Additional use of SAMA plus LABA showed a significant improvement in the peak response in FEV1 (mean difference (MD) 98.70 mL, p < .00001), transitional dyspnea index score (MD .85, p = .02), and St George's Respiratory Questionnaire score (MD -2.00, p = .008) compared to LABA treatment. There was no significant difference in the risk of exacerbation of COPD (p = .20) and only a slight trend of increased severe adverse events (OR: 2.16, p = .08) and cardiovascular events (OR: 2.38, p = .06). CONCLUSION Additional treatment with SAMA combined with LABA could be a feasible choice due to its efficacy and safety.
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Affiliation(s)
- Kazuya Tanimura
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukio Fujita
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
| | - Yoshifumi Yamamoto
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
| | - Takashi Hajiro
- Department of Respiratory Medicine, 13802Tenri Hospital, Tenri, Japan
| | - Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, 26333Kurume University School of Medicine, Kurume, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, 12967Nara Medical University, Kashihara, Japan
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Benfante A, Tomasello A, Gianquinto E, Cicero MN, Scichilone N. Diagnostic and therapeutic approaches for elderly asthma patients: the importance of multidisciplinary and multidimensional management. Expert Rev Respir Med 2023; 17:459-468. [PMID: 37194689 DOI: 10.1080/17476348.2023.2215432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Asthma is commonly considered a disease of younger ages; however, it is not infrequent to pose a diagnosis of the disease in older individuals. Although current recommendations do not distinguish between young and old asthmatics in terms of diagnostic and therapeutic approaches, asthma in the elderly may present with peculiar features that contribute to complicate its management. AREAS COVERED The current review focuses on the challenges that arise when approaching an older individual with suspected asthma. Age-associated changes of the lung may complicate the diagnostic approach. Measurement of the forced expiratory volume in the first 6 s (FEV6) in an easier and faster alternative to FVC estimation, and residual volume should always be assessed. Older individuals are often affected by concomitant diseases, both age- and drug-related, that need to be considered when approaching elderly asthmatics, since they can affect the efficacy of the treatment as well as the control of the disease. EXPERT OPINION The potential drug to drug interaction should be routinely investigated, and documented in medical records. The effect of aging on the response to pharmacological therapy in older asthmatics should be explored. Therefore, the need of a multidisciplinary and multidimensional approach to the elderly asthmatics is strongly encouraged.
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Affiliation(s)
- Alida Benfante
- PROMISE Department, University of Palermo, Palermo, Italy
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Lopez-Campos JL, Almagro P, Gómez JT, Chiner E, Palacios L, Hernández C, Navarro MD, Molina J, Rigau D, Soler-Cataluña JJ, Calle M, Cosío BG, Casanova C, Miravitlles M. Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care. Arch Bronconeumol 2022; 58:334-344. [PMID: 35315327 DOI: 10.1016/j.arbres.2021.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
The current health care models described in GesEPOC indicate the best way to make a correct diagnosis, the categorization of patients, the appropriate selection of the therapeutic strategy and the management and prevention of exacerbations. In addition, COPD involves several aspects that are crucial in an integrated approach to the health care of these patients. The evaluation of comorbidities in COPD patients represents a healthcare challenge. As part of a comprehensive assessment, the presence of comorbidities related to the clinical presentation, to some diagnostic technique or to some COPD-related treatments should be studied. Likewise, interventions on healthy lifestyle habits, adherence to complex treatments, developing skills to recognize the signs and symptoms of exacerbation, knowing what to do to prevent them and treat them within the framework of a self-management plan are also necessary. Finally, palliative care is one of the pillars in the comprehensive treatment of the COPD patient, seeking to prevent or treat the symptoms of a disease, the side effects of treatment, and the physical, psychological and social problems of patients and their caregivers. Therefore, the main objective of this palliative care is not to prolong life expectancy, but to improve its quality. This chapter of GesEPOC 2021 presents an update on the most important comorbidities, self-management strategies, and palliative care in COPD, and includes a recommendation on the use of opioids for the treatment of refractory dyspnea in COPD.
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Affiliation(s)
- José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Pere Almagro
- Servicio de Medicina Interna, Hospital Universitario Mutua de Tarrasa, Tarrasa, Barcelona, España
| | | | - Eusebi Chiner
- Servicio de Neumología, Hospital Universitario San Juan de Alicante, Alicante, España
| | - Leopoldo Palacios
- Unidad de Gestión Clínica El Torrejón, Distrito Sanitario Huelva-Costa y Condado-Campiña, Huelva, España
| | - Carme Hernández
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Dispositivo transversal hospitalización a domicilio, Dirección Médica y Enfermera, Hospital Clínic, Universidad de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | | | - Jesús Molina
- Centro de Salud Francia, Dirección Asistencial Oeste, Fuenlabrada, Madrid, España
| | - David Rigau
- Centro Cochrane Iberoamericano, Barcelona, España
| | | | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Borja G Cosío
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Baleares, España
| | - Ciro Casanova
- Unidad de Investigación, Servicio de Neumología, Hospital Universitario de La Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Tenerife, España
| | - Marc Miravitlles
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
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7
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Lopez-Campos JL, Almagro P, Gómez JT, Chiner E, Palacios L, Hernández C, Navarro MD, Molina J, Rigau D, Soler-Cataluña JJ, Calle M, Cosío BG, Casanova C, Miravitlles M. [Translated article] Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care. ARCHIVOS DE BRONCONEUMOLOGÍA 2022. [DOI: 10.1016/j.arbres.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jackevicius CA. A practical introduction to conducting and using
case‐control
studies. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Cynthia A. Jackevicius
- Department of Pharmacy Practice and Administration, College of Pharmacy Western University of Health Sciences Pomona California USA
- Department of Pharmacy Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California USA
- ICES (formerly Institute for Clinical Evaluative Sciences) Toronto Canada
- Institute of Health Policy, Management and Evaluation University of Toronto Toronto Canada
- Department of Pharmacy University Health Network Toronto Canada
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Baboudjian M, Gondran-Tellier B, Tadrist A, Brioude G, Trousse D, D'Journo BX, Thomas PA. Predictors of Postoperative Urinary Retention Following Pulmonary Resection. Semin Thorac Cardiovasc Surg 2021; 33:1137-1143. [PMID: 33677097 DOI: 10.1053/j.semtcvs.2021.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023]
Abstract
To identify predictors of postoperative urinary retention (POUR) following pulmonary resection. Retrospective chart review from a single academic institution of all patients who underwent pulmonary resection between June 2004 and January 2020. The surgical procedures consisted of pneumonectomy, lobectomy and sublobar resections. The primary outcome was occurrence of POUR within 30 days following surgery, defined as painful and palpable bladder, when the patient is unable to pass any urine, and requiring catheterization. A total of 6004 consecutive patients underwent pulmonary resection among which 306 pneumonectomies (5.1%), 3467 lobectomies (57.7%) and 2231 sublobar resection (37.2%). The surgical approach was a thoracotomy (n = 3546; 59.1%), a video-assisted [VATS] (n = 2075; 34.5%) or a robot-assisted thoracoscopy [RATS] (n = 383; 6.4%). POUR occurred in 301 cases (5%). On multivariable logistic regression analysis, male gender (OR 2.30 [1.70-3.17]; P < 0.001), age (OR 1.02 [1.01-1.03]; P < 0.001), benign prostatic hyperplasia (OR 7.08 [4.57-10.83]; P < 0.001), and COPD (OR 1.52 [1.13-2.01]; P = 0.004) were significant predictors of POUR. Conversely, VATS (OR 0.62 [0.46-0.83]; P = 0.001) had a protective effect on the occurrence of POUR. In a large single-center study, we disclosed significant clinical predictors of POUR after pulmonary resection, including age, sex, comorbidities and surgical approach. Prospective studies are necessary to evaluate the efficacy of chemoprophylaxis by perioperative α-blockers in order to prevent POUR.
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Affiliation(s)
- Michael Baboudjian
- Department of Thoracic Surgery, Diseases of the Esophagus, and lung Transplantation, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Bastien Gondran-Tellier
- Department of Urology and Kidney Transplantation, La conception Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Abel Tadrist
- Department of Thoracic Surgery, Diseases of the Esophagus, and lung Transplantation, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Geoffrey Brioude
- Department of Thoracic Surgery, Diseases of the Esophagus, and lung Transplantation, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Delphine Trousse
- Department of Thoracic Surgery, Diseases of the Esophagus, and lung Transplantation, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Benoît Xavier D'Journo
- Department of Thoracic Surgery, Diseases of the Esophagus, and lung Transplantation, North Hospital, Aix-Marseille University, APHM, Marseille, France; Predictive Oncology Laboratory, CRCM, INSERM UMR 1068, CNRS UMR 7258, Aix-Marseille University UM105, Marseille, France
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgery, Diseases of the Esophagus, and lung Transplantation, North Hospital, Aix-Marseille University, APHM, Marseille, France; Predictive Oncology Laboratory, CRCM, INSERM UMR 1068, CNRS UMR 7258, Aix-Marseille University UM105, Marseille, France.
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Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. J Am Geriatr Soc 2019; 67:1123-1127. [PMID: 30697698 DOI: 10.1111/jgs.15798] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 11/29/2022]
Abstract
Older adults are prescribed a growing number of medications. Polypharmacy, commonly considered the receipt of five or more medications, is associated with a range of adverse outcomes. There is a debate about the reason(s) why. On one side is the assertion that older persons are being prescribed too many medications, with the number of medications increasing the risk of adverse events. On the other side is the observation that polypharmacy is associated both with overprescribing of inappropriate medications and underprescribing of appropriate medications. This leads to the concept of "inappropriate" vs "appropriate" polypharmacy, with the latter resulting from the prescription of many correct medications to persons with multiple chronic conditions. Few studies have examined the health outcomes associated with adding and/or removing medications to address this debate directly. The criteria used to identify underutilized medications are based on results of randomized controlled trials that may not be generalizable to older adults. Several randomized controlled trials and many more observational studies provide evidence that these criteria overestimate medication benefits and underestimate harms. In addition, evidence suggests that the marginal effects of medications added to an already complex regimen differ from their effects when considered individually. Although in selected circumstances adding medications results in benefit to patients, patients with multimorbidity and frailty/disability have susceptibilities that can decrease the likelihood of medication benefit and increase the likelihood of harms. The identification of appropriate polypharmacy requires more robust criteria to evaluate the net effects of complex medication regimens.
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Affiliation(s)
- Terri R Fried
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Marcia C Mecca
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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Abad-Arranz M, Moran-Rodríguez A, Mascarós Balaguer E, Quintana Velasco C, Abad Polo L, Núñez Palomo S, Gonzálvez Rey J, Fernández Vargas AM, Hidalgo Requena A, Helguera Quevedo JM, García Pardo M, Lopez-Campos JL. Community Assessment of COPD Health Care (COACH) study: a clinical audit on primary care performance variability in COPD care. BMC Med Res Methodol 2018; 18:68. [PMID: 29970023 PMCID: PMC6029063 DOI: 10.1186/s12874-018-0528-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 06/20/2018] [Indexed: 12/01/2022] Open
Abstract
Background A thorough evaluation of the adequacy of clinical practice in a designated health care setting and temporal context is key for clinical care improvement. This study aimed to perform a clinical audit of primary care to evaluate clinical care delivered to patients with COPD in routine clinical practice. Methods The Community Assessment of COPD Health Care (COACH) study was an observational, multicenter, nationwide, non-interventional, retrospective, clinical audit of randomly selected primary care centers in Spain. Two different databases were built: the resources and organization database and the clinical database. From January 1, 2015 to December 31, 2016 consecutive clinical cases of COPD in each participating primary care center (PCC) were audited. For descriptive purposes, we collected data regarding the age at diagnosis of COPD and the age at audit, gender, the setting of the PCC (rural/urban), and comorbidities for each patient. Two guidelines widely and uniformly used in Spain were carefully reviewed to establish a benchmark of adequacy for the audited cases. Clinical performance was analyzed at the patient, center, and regional levels. The degree of adequacy was categorized as excellent (> 80%), good (60–80%), adequate (40–59%), inadequate (20–39%), and highly inadequate (< 20%). Results During the study 4307 cases from 63 primary care centers in 6 regions of the country were audited. Most evaluated parameters were judged to fall in the inadequate performance category. A correct diagnosis based on previous exposure plus spirometric obstruction was made in an average of 17.6% of cases, ranging from 9.8 to 23.3% depending on the region. During the audited visit, only 67 (1.6%) patients had current post-bronchodilator obstructive spirometry; 184 (4.3%) patients had current post-bronchodilator obstructive spirometry during either the audited or initial diagnostic visit. Evaluation of dyspnea was performed in 11.1% of cases. Regarding treatment, 33.6% received no maintenance inhaled therapies (ranging from 31.3% in GOLD A to 7.0% in GOLD D). The two most frequently registered items were exacerbations in the previous year (81.4%) and influenza vaccination (87.7%). Conclusions The results of this audit revealed a large variability in clinical performance across centers, which was not fully attributable to the severity of the disease.
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Affiliation(s)
- María Abad-Arranz
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Avda. Manuel Siurot, s/n, 41013, Seville, Spain
| | | | | | | | | | | | | | | | | | | | | | - Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Avda. Manuel Siurot, s/n, 41013, Seville, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
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LaForce C, Derom E, Bothner U, Kloer IM, Trampisch M, Buhl R. Long-term safety of tiotropium/olodaterol Respimat ® in patients with moderate-to-very severe COPD and renal impairment in the TONADO ® studies. Int J Chron Obstruct Pulmon Dis 2018; 13:1819-1831. [PMID: 29910611 PMCID: PMC5987861 DOI: 10.2147/copd.s161489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The safety, lung function efficacy, and symptomatic benefits of combined tiotropium and olodaterol in patients with COPD were established in the 1-year TONADO® studies (NCT01431274; NCT01431287). As tiotropium is predominantly excreted by the kidneys, the long-term safety profile of tiotropium/olodaterol was investigated in patients with renal impairment in a prespecified safety analysis of the TONADO studies. Methods These were 2 replicate, randomized, double-blind, parallel-group, 52-week Phase III studies that assessed tiotropium/olodaterol compared with tiotropium or olodaterol alone (all via Respimat®) in patients with moderate-to-very severe COPD. In this analysis, renal impairment was defined as mild (creatinine clearance [CLcr] 60–89 mL/min), moderate (CLcr 30–59 mL/min) or severe (CLcr 15–29 mL/min). Adverse events (AEs) were pooled from both studies. Results Of 3,041 patients included in this analysis, 1,333 (43.8%) had mild, 404 (13.3%) had moderate, and 5 (0.2%) had severe renal impairment; these were distributed equally between treatment groups. Almost one-quarter of all treated patients (23.4%) had a history of cardiac disorder, 45.6% had hypertension, and 13.3% had glucose metabolism disorders, including diabetes. AEs with olodaterol, tiotropium, and tiotropium/olodaterol occurred in 75.1%, 70.8%, and 72.0% of patients with no renal impairment, 75.7%, 74.0%, and 73.3% with mild renal impairment, and 84.3%, 79.5%, and 79.7% with moderate renal impairment, respectively. There was no notable effect of renal impairment on the proportion of patients with an AE, and no differences were observed between tiotropium/olodaterol versus the monocomponents. There was no difference in the incidence of major adverse cardiac events, renal and urinary tract AEs, or potential anticholinergic effects with increasing severity of renal impairment. Conclusion Over half the patients enrolled in the TONADO studies had renal impairment, and there was a high level of pre-existing cardiovascular comorbidity. The safety and tolerability of tiotropium/olodaterol is comparable to the monocomponents, irrespective of the level of renal impairment.
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Affiliation(s)
| | - Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ulrich Bothner
- Pharmacovigilance, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Isabel M Kloer
- Pharmacovigilance, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Matthias Trampisch
- Biostatistics & Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
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Polypharmacy, chronic kidney disease, and benign prostatic hyperplasia in patients with chronic obstructive pulmonary disease newly treated with long-acting anticholinergics. Respir Med 2017; 132:195-202. [PMID: 29229097 DOI: 10.1016/j.rmed.2017.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/27/2017] [Accepted: 10/28/2017] [Indexed: 11/20/2022]
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Gershon AS, Newman AM, Fischer HD, Austin PC, Daneman N, Bell CM, Stephenson AL, Gill SS, Vozoris NT, Rochon PA. Inhaled Long-acting Anticholinergics and Urinary Tract Infection in Individuals with COPD. COPD 2016; 14:105-112. [DOI: 10.1080/15412555.2016.1202912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Andrea S. Gershon
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alice M. Newman
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Hadas D. Fischer
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chaim M. Bell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne L. Stephenson
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sudeep S. Gill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nicholas T. Vozoris
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Paula A. Rochon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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Factors responsible for poor sleep quality in patients with chronic obstructive pulmonary disease. BMC Pulm Med 2016; 16:118. [PMID: 27501837 PMCID: PMC4977946 DOI: 10.1186/s12890-016-0281-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/04/2016] [Indexed: 11/30/2022] Open
Abstract
Background Sleep disturbance is a common complaint in patients with chronic obstructive lung disease (COPD). However, the factors resulting in sleep disturbance remain unclear. This retrospective, observational, multicenter study aimed to identify the factors associated with sleep disturbance in patients with COPD. Methods The study was a retrospective, observational, and multicenter research. Data including age, sex, body mass index, smoking status, COPD inhaler prescribed, clinical symptoms, pulmonary function tests, medical history of comorbidities, and questionnaires were collected. Parameters including demographics, symptoms, medication, severity, functional classification, and comorbidities were correlated with sleep quality scores. Results Among 377 patients with COPD, 200 (53 %) patients experienced poor sleep quality (Pittsburg Sleep Quality Index scores > 5). A significant difference in sleep quality, as measured by PSQI scores, was noted between groups based on the 2011 Global Initiatives for Chronic Obstructive Lung Disease (GOLD) classification system. The most common sleep disturbances included “getting up to use the bathroom” (70.3 %), “wake up at night or early morning” (40.3 %), and “cough and snore loudly at night” (15.9 %). The use of inhaled corticosteroids, the presence of wheezing, COPD Assessment Test (CAT) scores, and Modified Medical Research Council (mMRC) dyspnea scale scores positively correlated with poor sleep quality (odds ratio: 1.51, 1.66, 1.09, and 1.30, respectively). Upon multivariate analysis, the CAT score was an independent factor for poor sleep quality in these patients. With the exception of sleep problem items, based on the CAT questionnaire, phlegm was significantly higher in COPD patients with poor sleep quality. Conclusions Poor sleep quality is common among patients with COPD and symptoms including wheeze, phlegm, and inhaled corticosteroid use may contribute to poor sleep quality. The CAT score is a good indicator of poor sleep quality in patients with COPD.
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Tashkin DP. The safety of anticholinergic bronchodilators for the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Saf 2015; 14:1759-72. [PMID: 26401729 DOI: 10.1517/14740338.2015.1093621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Poorly absorbable quaternary ammonium-inhaled muscarinic antagonists both as the short-acting ipratropium and as long-acting (12 - 24 h) agents (tiotropium, glycopyrronium, aclidinium and umeclidinium) have all demonstrated statistically and clinically significant efficacy in chronic obstructive pulmonary disease compared with placebo. However, controversy has arisen concerning the safety of this class of agents principally regarding their association with both fatal and nonfatal cardiovascular toxicity. AREAS COVERED The safety of both ipratropium and the long-acting muscarinic antagonists is reviewed with a major emphasis on potential cardiovascular toxicity, based on published clinical trials data and results of analyses of pooled data, meta-analyses, and observational studies. Since glycopyrronium, aclidinium, and umeclidinium have become available only relatively recently, more emphasis will be placed on the more extensive literature concerning the safety of the older anticholinergic compounds, the short-acting ipratropium, and the long-acting tiotropium in its dry powder formulation, as well as its newer soft mist inhaler delivery device. EXPERT OPINION Pooled analyses and meta-analyses of randomized controlled trials (RCTs) of tiotropium in both its dry powder and soft mist formulations, as well as some observational studies, have implicated this agent as increasing the risk of nonfatal and fatal cardiovascular events. However, the most robust evidence based on large-scale randomized controlled trials (RCTs) of relatively long duration specifically designed to evaluate the cardiovascular safety of tiotropium have not confirmed these safety concerns. Because of the relatively limited amount of safety data for the newer long-acting muscarinic antagonists compared to the far more extensive experience with tiotropium, it will be important to accumulate additional safety information from post-marketing pharmacovigilance for these newer agents.
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Affiliation(s)
- D P Tashkin
- a Professor of Medicine, University of California-Los Angeles - Medicine, David Geffen School of Medicine at UCLA , 10833 Le Conte Ave, Los Angeles, California 90095, USA +1 31 08 25 31 63 ; +1 31 02 06 50 88 ;
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Vaz Fragoso CA, Pretto JJ, Quanjer PH. Comment on: Wollmer P, Engström G. Fixed ratio or lower limit of normal (LLN) as cut-off value for FEV1/VC: An outcome study. Respiratory Medicine (2013) 107, 1460-1462.: Fixed ratio or lower limit of normal (LLN) as cut-off value for FEV1/VC. Respir Med 2015; 109:928. [PMID: 25979574 DOI: 10.1016/j.rmed.2013.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 12/18/2022]
Affiliation(s)
- Carlos A Vaz Fragoso
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA; Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT, USA.
| | - Jeffrey J Pretto
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Philip H Quanjer
- Department of Pulmonary Diseases, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands; Department of Paediatrics, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands
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Hashimoto M, Hashimoto K, Ando F, Kimura Y, Nagase K, Arai K. Prescription rate of medications potentially contributing to lower urinary tract symptoms and detection of adverse reactions by prescription sequence symmetry analysis. J Pharm Health Care Sci 2015; 1:7. [PMID: 26819718 PMCID: PMC4728807 DOI: 10.1186/s40780-014-0004-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 10/29/2014] [Indexed: 01/18/2023] Open
Abstract
Background The lower urinary tract symptoms (LUTS) increases with age and can have a significant effect on the quality of life of the patients. Elderly patients, who are often characterized by a decline in physiological functional and polypharmacy, are susceptible to adverse drug reactions to pharmacotherapy. LUTS can also be a side effect of medication. The purpose of this study was to investigate the possible association between the initiation of LUTS-causing drug therapy and the onset of LUTS. Methods Drug dispensing data at the individual level were retrieved from the CISA (Platform for Clinical Information Statistical Analysis: http://www.cisa.jp) database. A retrospective study was conducted by reviewing patients with LUTS who were dispensed drugs that increased the risk of LUTS between April 2011 and March 2012. Prescription sequence symmetry analysis (PSSA) was employed to investigate the associations between the dispensing of medicines of LUTS and that of LUTS-causing drugs. Results LUTS-causing drugs were frequently dispensed to patients with LUTS. The use of medications potentially contributing to LUTS was associated with polypharmacy [number of prescription drugs:12.13 ± 6.78 (user) vs. 5.67 ± 5.24 (nonuser)] but not patient age [ age: (71.38 ± 13.28 (user) vs. 70.45 ± 14.80 (nonuser)]. Significant adverse drug events were observed the use of donepezil, cyclophosphamide, antiparkinson drugs, antidepressant, diazepam, antipsychotic drugs for peptic ulcer, tiotropium bromide, and opioids. Conclusions The use of prescription LUTS-causing drugs was correlated with polypharmacy. The adverse drug events associated with LUTS-causing drugs were highly prevalent in elderly patients. To prevent of adverse drug events in patients with LUTS, pharmacists and physicians should regularly review medication lists and reduce the prescribed medicines. Electronic supplementary material The online version of this article (doi:10.1186/s40780-014-0004-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Masako Hashimoto
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kakuma-machi, Kanazawa, 920-1192 Japan.,Temari Pharmacy, 2-50 Kobu-machi, Kanazawa, 920-0362 Japan
| | - Kanako Hashimoto
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kakuma-machi, Kanazawa, 920-1192 Japan
| | - Fumihiko Ando
- Department of Medical Informatics, Kyoto University Hospital, 54 Kawaharacho, Syogoin, Sakyu-ku Kyoto, 606-8507 Japan
| | - Yoshiaki Kimura
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kakuma-machi, Kanazawa, 920-1192 Japan.,Suisen Pharmacy, Fukui Pharmaceutical Association, 906 Matsuokagokuryo Yoshida-gun Eiheijicho-cho, Fukui, 910-1193 Japan
| | - Keisuke Nagase
- Department of Medical Informatic, Kanazawa University Hospital, 2-251 Takara-machi, Kanazawa, 920-8641 Japan
| | - Kunizo Arai
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kakuma-machi, Kanazawa, 920-1192 Japan
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Loke YK, Singh S. Risks associated with tiotropium in chronic obstructive pulmonary disease: overview of the evidence to date. Ther Adv Drug Saf 2014; 3:123-31. [PMID: 25083231 DOI: 10.1177/2042098612438388] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Tiotropium is a long-acting inhaled anticholinergic agent that is widely used in the treatment of chronic obstructive pulmonary disease (COPD). It was initially launched as the tiotropium HandiHaler formulation, but this was followed by a newer version based on a potentially more efficient drug delivery device, known as Respimat. This Respimat formulation is available worldwide but has not yet succeeded in gaining regulatory approval in the USA. In the past few years, the adverse effects profile of tiotropium has come under close scrutiny owing to concerns about the possibility of urinary and cardiovascular adverse effects. These concerns appeared to have been alleviated following the publication of data from the Understanding Potential Long-Term Impacts on Function with Tiotropium (UPLIFT) trial, which was a large trial of 4 years' duration. This trial did not show any excess myocardial infarction, renal or urinary adverse events with tiotropium compared with placebo. However, the risk of urinary retention has been in the spotlight again following publication of two observational studies reporting a significantly increased risk of urinary retention in men recently started on inhaled anticholinergics, especially when prostatic hyperplasia coexists. More recently, a meta-analysis of mortality data for the tiotropium Respimat formulation raised the possibility of an increased risk of death, including death from cardiovascular causes. It is unclear if the more efficient drug delivery offered by the Respimat device is hitting a different part of the dose-toxicity curve. In the absence of any evidence of superior clinical efficacy with tiotropium Respimat compared with tiotropium HandiHaler, some experts have argued that there is no compelling reason to choose the Respimat formulation given the new uncertainties about its safety profile.
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Affiliation(s)
- Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Sonal Singh
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Loke YK, Singh S. Risk of acute urinary retention associated with inhaled anticholinergics in patients with chronic obstructive lung disease: systematic review. Ther Adv Drug Saf 2014; 4:19-26. [PMID: 25083248 DOI: 10.1177/2042098612472928] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inhaled anticholinergics (ipratropium bromide and tiotropium bromide) are widely used as maintenance treatment in chronic obstructive pulmonary disease. Previous studies have reported on their cardiovascular effects but relatively little is known about their effects on the bladder. Acute urinary retention is a medical emergency which can be associated with serious complications. Our objective was to evaluate the existing literature regarding the effects of inhaled anticholinergics on urinary retention among patients with chronic obstructive pulmonary disease. We searched PubMed and the United States Food and Drug Administration (FDA) adverse events database for case reports, observational studies, randomized controlled trials (or meta-analyses of such trials) that reported on the outcome of urinary retention with inhaled anticholinergics (ipratropium or tiotropium). We checked 27 published articles and identified relevant papers including two case reports, three pooled analyses, two observational studies and one randomized controlled trial. Two of the observational studies and a pooled analysis of randomized controlled trials reported a significant increase in the risk of acute urinary retention with inhaled anticholinergics. Older patients with benign prostatic hyperplasia seem to be at the highest risk of this adverse effect which tends to occur soon after treatment initiation. Although all the links in the chain have yet to be fully elucidated, the preponderance of evidence suggests the possibility of a causal relationship between inhaled anticholinergics and urinary retention. Clinicians should carefully balance these and other adverse effects of inhaled anticholinergics against their known symptomatic benefits on exacerbations, after eliciting patient preferences for various outcomes in a shared decision-making context.
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Affiliation(s)
- Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ UK
| | - Sonal Singh
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Malerba M, Morjaria JB, Radaeli A. Differential pharmacology and clinical utility of emerging combination treatments in the management of COPD--role of umeclidinium/vilanterol. Int J Chron Obstruct Pulmon Dis 2014; 9:687-95. [PMID: 25061288 PMCID: PMC4085305 DOI: 10.2147/copd.s47792] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease characterized by airflow limitation that is not fully reversible. Bronchodilator therapy is the cornerstone in COPD treatment. Bronchodilation in COPD is mainly achieved via administration of long- and ultralong-acting β2-agonists and with long-acting muscarinic antagonists. New combinations of bronchodilators with dual-acting muscarinic antagonist and β2-agonist properties have been licensed, and others are currently being developed with the aim of achieving once-daily dosing, and therefore may improve the likelihood of treatment compliance. These combination bronchodilators include glycopyrronium bromide/indacaterol maleate, umeclidinium (UMEC) bromide/vilanterol trifenatate (VI), aclidinium bromide/formoterol and tiotropium bromide/olodaterol (Boehringer Ingelheim, Germany). This review will focus mainly on studies and clinical trials involving the novel fixed-dose combination of UMEC/VI at doses of 125/25 μg and 62.5/25 μg in patients with COPD. Data from large clinical trials involving more than 4,500 COPD patients indicate that UMEC/VI is an effective once-daily treatment in COPD with improved pulmonary function. Future studies assessing the impact of this combination on exacerbations, delay in disease progression, and health status in patients with COPD are warranted.
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Affiliation(s)
- Mario Malerba
- Department of Internal Medicine, University of Brescia, Brescia, Italy
| | - Jaymin Bhagwanji Morjaria
- Department of Academic Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, United Kingdom
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Abstract
Databases are electronic filing systems that have been set up to capture patient data in a variety of clinical and administrative settings. While randomised controlled trials are the gold standard for the evaluation of healthcare interventions, electronic databases are valuable research options for studies of aetiology and prognosis, or where trials are too expensive/not logistically feasible. However, databases exist in many different settings and formats (often developed for administrative or financial reimbursement purposes rather than clinical research), and researchers need to put careful thought into identifying and acquiring relevant data sets. Accuracy of records and validation of diagnoses are key issues when planning a database study. High-quality databases can readily capture outcome data (as part of routine clinical care) without the costs and burden of additional trial-related follow-up, and there are promising hybrid models which combine the benefits of randomisation with the efficiency of outcome ascertainment using existing databases.
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Abstract
The appropriate management of chronic obstructive pulmonary disease (COPD) involves more than taking prescription medicines. The key components have been set out in detail in many treatment guidelines, both national and international. They include the avoidance of identified risk factors, especially tobacco smoking, and the optimization of daily physical activity. This article reviews the key components of the pharmacologic treatment of COPD, both acute and chronic, with an emphasis on those recent studies, which are likely to change practice in the next few years.
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Affiliation(s)
- Peter Calverley
- Respiratory Research, Clinical Sciences Department, Institute of Ageing & Chronic Diseases, University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK.
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Effect of Oxygen-driven Nebulization at Different Oxygen Flows in Acute Exacerbation of Chronic Obstructive Pulmonary Disease Patients. Am J Med Sci 2014; 347:343-6. [DOI: 10.1097/maj.0b013e3182937766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW The use of anticholinergic medications is well established as maintenance therapy for chronic obstructive pulmonary disease (COPD). There is a growing interest in the use of anticholinergic medications in the treatment of moderate to severe asthma. The purpose of this review is to summarize the scientific evidence for the use of anticholinergic therapy in the management of asthma. RECENT FINDINGS Early case reports and small studies evaluated the use of the anticholinergic agent, tiotropium bromide, as maintenance therapy in asthma. Included in this review are several recent clinical trials which provide additional evidence for the use of tiotropium as add-on therapy for asthma. The use of tiotropium was demonstrated to be superior to doubling the dose of an inhaled corticosteroid (ICS) and more effective than placebo based on change in morning peak expiratory flow (PEF). Two large multinational trials provide evidence for the use of tiotropium in a subset of asthmatic patients who have not achieved control using combination therapy with an ICS and a long-acting β2 agonist (LABA). SUMMARY The use of the long-acting anticholinergic agent, tiotropium, as maintenance of therapy in asthma, has been shown to be effective in some patients with moderate to severe asthma who are uncontrolled on combination therapy with ICS and LABA. Further studies are needed to better define which phenotypic subset of patients would benefit from the use of tiotropium.
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Gupta V, Singh D. Aclidinium bromide for the treatment of chronic obstructive pulmonary disease. Expert Rev Respir Med 2014; 6:581-8. [DOI: 10.1586/ers.12.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Kaplan SA. Re: Inhaled Anticholinergic Agents and Acute Urinary Retention in Men with Lower Urinary Tract Symptoms or Benign Prostatic Hyperplasia. J Urol 2013; 190:979. [DOI: 10.1016/j.juro.2013.05.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Groves HK, Chang D, Palazzi K, Cohen S, Parsons JK. The incidence of acute urinary retention secondary to BPH is increasing among California men. Prostate Cancer Prostatic Dis 2013; 16:260-5. [DOI: 10.1038/pcan.2013.11] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 02/20/2013] [Accepted: 02/23/2013] [Indexed: 11/09/2022]
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WOC Nurse Consult. J Wound Ostomy Continence Nurs 2013; 40:97-100. [DOI: 10.1097/won.0b013e318270dc3e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Chronic obstructive pulmonary disease (COPD), a common disease in elderly patients, is characterized by high symptom burden, health care utilization, mortality, and unmet needs of patients and caregivers. Respiratory failure and dyspnea may be exacerbated by heart failure, pulmonary embolism, and anxiety; by medication effects; and by other conditions, including deconditioning and malnutrition. Randomized controlled trials, which provide the strongest evidence for guideline recommendations, may underestimate the risk of adverse effects of interventions for older patients with COPD. The focus of guidelines on disease-modifying therapies may not address the full spectrum of patient and caregiver needs, particularly the high rates of bothersome symptoms, risk of functional and cognitive decline, and need for end-of-life care planning. Meeting the many needs of older patients with COPD and their families requires that clinicians supplement guideline-recommended care with treatment decision making that takes into account older persons' comorbid conditions, recognizes the trade-offs engendered by the increased risk of adverse events, focuses on symptom relief and function, and prepares patients and their loved ones for further declines in the patient's health and their end-of-life care. A case of COPD in an 81-year-old man hospitalized with severe dyspnea and respiratory failure highlights both the challenges in managing COPD in the elderly and the limitations in applying guidelines to geriatric patients.
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Affiliation(s)
- Terri R Fried
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
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Karimi S, Dharia SP, Flora DS, Slattum PW. Anticholinergic Burden: Clinical Implications for Seniors and Strategies for Clinicians. ACTA ACUST UNITED AC 2012; 27:564-82. [DOI: 10.4140/tcp.n.2012.564] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Vande Griend JP, Linnebur SA. Inhaled anticholinergic agents and acute urinary retention in men with lower urinary tract symptoms or benign prostatic hyperplasia. Ann Pharmacother 2012; 46:1245-9. [PMID: 22851743 DOI: 10.1345/aph.1r282] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the risk of acute urinary retention with the use of inhaled anticholinergic agents in men with lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH). DATA SOURCES A literature search was performed with MEDLINE via PubMed from 1967 through May 2012 using the terms inhaled anticholinergics, urinary retention, benign prostatic hyperplasia, lower urinary tract symptoms, tiotropium, and ipratropium. In addition, references from reviewed publications were identified and official labeling was obtained from the manufacturers' Web sites. STUDY SELECTION AND DATA EXTRACTION Only English-language publications were included. Randomized controlled trial data, observational studies, case reports, package labeling, and commentaries regarding men with BPH/LUTS using inhaled anticholinergic agents and the associated development of urinary retention were reviewed. DATA SYNTHESIS Two case reports; 1 prospective, open-label, single-arm study; and 2 nested case-control studies evaluated or described the use of inhaled anticholinergic agents and the development of acute urinary retention in men with BPH/LUTS. Taken together, the available data demonstrate that treatment with inhaled anticholinergic agents is associated with acute urinary retention in men with preexisting LUTS or BPH. CONCLUSIONS Men with LUTS or BPH who are treated with inhaled anticholinergic agents may develop acute urinary retention, but this cannot be quantified based on the limited information available. Inhaled anticholinergic agents should be used when indicated in men with LUTS or BPH, but close monitoring and patient education should be implemented.
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Affiliation(s)
- Joseph P Vande Griend
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA.
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Gill TM. Respiratory impairment and COPD hospitalisation in older persons: a competing risk analysis. Eur Respir J 2012; 40:37-44. [PMID: 22267770 PMCID: PMC3773173 DOI: 10.1183/09031936.00128711] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The aim of the present study was to evaluate, among older persons, the association between respiratory impairment and hospitalisation for chronic obstructive pulmonary disease (COPD), based on spirometric Z-scores, i.e. the LMS (lambda, mu, sigma) method, and a competing risk approach. Using data on 3,563 white participants aged 65-80 yrs (from the Cardiovascular Health Study) we evaluated the association of LMS-defined respiratory impairment with the incident of COPD hospitalisation and the competing outcome of death without COPD hospitalisation, over a 5-yr period. Respiratory impairment included airflow limitation (mild, moderate or severe) and restrictive pattern. Over a 5-yr period, 276 (7.7%) participants had a COPD hospitalisation incident, whereas 296 (8.3%) died without COPD hospitalisation. The risk of COPD hospitalisation was elevated more than two-fold in LMS-defined mild and moderate airflow limitation and restrictive pattern (adjusted HR (95% CI): 2.25 (1.25-4.05), 2.54 (1.53- 4.22) and 2.65 (1.82-3.86), respectively), and more than eight-fold in LMS-defined severe airflow limitation (adjusted HR (95% CI) 8.33 (6.24-11.12)). Conversely, only LMS-defined restrictive-pattern was associated with the competing outcome of death without COPD hospitalisation (adjusted HR (95% CI) 1.68 (1.22-2.32)). In older white persons, LMS-defined respiratory impairment is strongly associated with an increased risk of COPD hospitalisation. These results support the LMS method as a basis for defining respiratory impairment in older persons.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Ave, Mailcode 151B, West Haven, CT, USA.
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Cazzola M, Page CP, Calzetta L, Matera MG. Pharmacology and therapeutics of bronchodilators. Pharmacol Rev 2012; 64:450-504. [PMID: 22611179 DOI: 10.1124/pr.111.004580] [Citation(s) in RCA: 307] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bronchodilators are central in the treatment of of airways disorders. They are the mainstay of the current management of chronic obstructive pulmonary disease (COPD) and are critical in the symptomatic management of asthma, although controversies around the use of these drugs remain. Bronchodilators work through their direct relaxation effect on airway smooth muscle cells. at present, three major classes of bronchodilators, β(2)-adrenoceptor (AR) agonists, muscarinic receptor antagonists, and xanthines are available and can be used individually or in combination. The use of the inhaled route is currently preferred to minimize systemic effects. Fast- and short-acting agents are best used for rescue of symptoms, whereas long-acting agents are best used for maintenance therapy. It has proven difficult to discover novel classes of bronchodilator drugs, although potential new targets are emerging. Consequently, the logical approach has been to improve the existing bronchodilators, although several novel broncholytic classes are under development. An important step in simplifying asthma and COPD management and improving adherence with prescribed therapy is to reduce the dose frequency to the minimum necessary to maintain disease control. Therefore, the incorporation of once-daily dose administration is an important strategy to improve adherence. Several once-daily β(2)-AR agonists or ultra-long-acting β(2)-AR-agonists (LABAs), such as indacaterol, olodaterol, and vilanterol, are already in the market or under development for the treatment of COPD and asthma, but current recommendations suggest the use of LABAs only in combination with an inhaled corticosteroid. In addition, some new potentially long-acting antimuscarinic agents, such as glycopyrronium bromide (NVA-237), aclidinium bromide, and umeclidinium bromide (GSK573719), are under development, as well as combinations of several classes of long-acting bronchodilator drugs, in an attempt to simplify treatment regimens as much as possible. This review will describe the pharmacology and therapeutics of old, new, and emerging classes of bronchodilator.
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Affiliation(s)
- Mario Cazzola
- Università di Roma Tor Vergata, Dipartimento di Medicina Interna, Via Montpellier 1, 00133 Roma, Italy.
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Vaz Fragoso CA, Gill TM. Respiratory impairment and the aging lung: a novel paradigm for assessing pulmonary function. J Gerontol A Biol Sci Med Sci 2012; 67:264-75. [PMID: 22138206 PMCID: PMC3297762 DOI: 10.1093/gerona/glr198] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 10/02/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Older persons have an increased risk of developing respiratory impairment because the aging lung is likely to have experienced exposures to environmental toxins as well as reductions in physiological capacity. METHODS Systematic review of risk factors and measures of pulmonary function that are most often considered when defining respiratory impairment in aging populations. RESULTS Across the adult life span, there are frequent exposures to environmental toxins, including tobacco smoke, respiratory infections, air pollution, and occupational dusts. Concurrently, there are reductions in physiological capacity that may adversely affect ventilatory control, respiratory muscle strength, respiratory mechanics, and gas exchange. Recent work has provided a strong rationale for defining respiratory impairment as an age-adjusted reduction in spirometric measures of pulmonary function that are independently associated with adverse health outcomes. Specifically, establishing respiratory impairment based on spirometric Z-scores has been shown to be strongly associated with respiratory symptoms, frailty, and mortality. Alternatively, respiratory impairment may be defined by the peak expiratory flow, as measured by a peak flow meter. The peak expiratory flow, when expressed as a Z-score, has been shown to be strongly associated with disability and mortality. However, because it has a reduced diagnostic accuracy, peak expiratory flow should only define respiratory impairment when spirometry is not readily available or an older person cannot adequately perform spirometry. CONCLUSIONS Aging is associated with an increased risk of developing respiratory impairment, which is best defined by spirometric Z-scores. Alternatively, in selected cases, respiratory impairment may be defined by peak expiratory flow, also expressed as a Z-score.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Department of Internal Medicine, Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut 06516, USA.
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Practical management problems of stable chronic obstructive pulmonary disease in the elderly. Curr Opin Pulm Med 2012; 17 Suppl 1:S43-8. [PMID: 22209930 DOI: 10.1097/01.mcp.0000410747.20958.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) is one of the most prevalent and increasing health problems in the elderly on a worldwide scale. The management of COPD in older patients presents practical diagnostic and treatment issues, which are reviewed with reference to the stable stage of the disease. RECENT FINDINGS In the diagnostic approach of COPD in the elderly the use of spirometry is recommended, but both patient conditions (such as inability to correctly perform it due to fatigue, lack of coordination, and cognitive impairment) and metrics characteristics should be taken into account for the test performance. It has been demonstrated in population studies that the use of the fixed ratio determines a substantial overdiagnosis of COPD in the oldest patients. Other parameters have been suggested [such as the evaluation of Lower Limit of Normality (LLN) for the FEV1/FVC ratio], which may be useful to guide the diagnosis. Several nonpharmacologic - such as smoking cessation, vaccination, physical activity, and pulmonary rehabilitation, nutrition, and eventually invasive ventilation - and pharmacologic interventions have been shown to improve outcomes and have been reviewed. Effective management of COPD in older adults should always consider the ability of patients to properly use inhalers and the involvement of caregivers or family members as a useful support to care, especially when treating cognitively impaired patients. Especially in the older population, timely identification and treatment of comorbidities are also crucial, but evidence in this area is still lacking and clinical practice guidelines do not take comorbidities into account in their recommendations. SUMMARY The Global Initiative for Obstructive Lung Disease has recommended criteria for diagnosis and management of COPD in the general population. On the contrary, available evidence suggests practical limitations in diagnostic approach and intervention strategies in older patients with stable COPD that need to be further studied for a translation into clinical practice guidelines.
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Abstract
PURPOSE OF REVIEW Defining the nature of the association between chronic obstructive pulmonary disease (COPD) and other chronic conditions is of primary importance to improve the health status of COPD patients through the optimal care of comorbidities. We aimed at providing a reasoned guide to understand, recognize and treat comorbidity of COPD with the perspective of shifting from comorbidity to multimorbidity. RECENT FINDINGS Select comorbidities, such as atherosclerotic disease, depression, chronic kidney disease, cognitive impairment, obstructive sleep apnea syndrome, lung cancer, osteoporosis, diabetes, heart failure, sarcopenia, aortic aneurysm, arrhythmias and pulmonary embolism are highly prevalent among older COPD patients. Several concerns may affect the management of older COPD patients with comorbidity (e.g. the use of β-blockers in patients with COPD and cardiovascular diseases or concerns about the cardiovascular safety of inhaled COPD drugs). SUMMARY Evidence suggests that systemic inflammation may be the link between COPD and comorbidities, but this issue is still debated. Whatever the mechanism underlying comorbidities in COPD may be, it has an important clinical, prognostic and therapeutic impact. Nevertheless, clinical practice guidelines do not take into account comorbidities in their recommendations. Additionally, clinical trials investigating COPD treatment in the context of multimorbidity and considering geriatric outcomes are also distinctly lacking.
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Thorpe CT, Lassila HC, O'Neil CK, Thorpe JM, Hanlon JT, Maher RL. Reconsideration of key articles regarding medication-related problems in older adults from 2011. THE AMERICAN JOURNAL OF GERIATRIC PHARMACOTHERAPY 2012; 10:2-13. [PMID: 22330099 PMCID: PMC3378666 DOI: 10.1016/j.amjopharm.2012.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 01/04/2012] [Indexed: 05/31/2023]
Affiliation(s)
- Carolyn T Thorpe
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Gavaldà A, Gras J, Llupià J, Aubets J, Beleta J, Llenas J. Aclidinium bromide, a novel long-acting muscarinic antagonist for COPD with improved preclinical renal and urinary safety profile. Life Sci 2011; 90:301-5. [PMID: 22213116 DOI: 10.1016/j.lfs.2011.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 11/01/2011] [Accepted: 12/05/2011] [Indexed: 11/16/2022]
Abstract
AIMS Aclidinium bromide is a novel, long-acting, inhaled muscarinic antagonist currently in registration phase for the treatment of chronic obstructive pulmonary disease. Since urinary difficulty and retention have been reported for anticholinergic agents such as tiotropium and ipratropium, it is important to examine the preclinical urinary and renal safety profile of aclidinium. MAIN METHODS The effect of aclidinium on urine and electrolyte excretion, renal function and voiding cystometry was analysed in conscious water-loaded Wistar rats (10-1000 μg/kg, s.c.), anaesthetised Beagle dogs (1000 μg/kg, i.v.) and anaesthetised guinea pigs (3-100μg/kg, intratracheally), respectively. Aclidinium plasma levels were determined in an independent study. Active comparators were tiotropium (all studies) and ipratropium (cystometry only). KEY FINDINGS Aclidinium 1000 μg/kg had no effect on urine excretion in rats, in contrast to tiotropium 100 μg/kg which significantly decreased this parameter (p<0.05). Aclidinium 1000 μg/kg also had no effect on renal function in Beagle dogs. In guinea pigs, aclidinium 3-100 μg/kg had no effect on urinary bladder function, whereas tiotropium and ipratropium 100 μg/kg decreased the peak micturition pressure (p<0.05), increased the volume of urine retained in the bladder (p<0.01) and showed a trend to decrease the volume of urine excreted. SIGNIFICANCE Aclidinium had no significant effect on urinary and renal function in the animal models studied. These results, together with the rapid plasma clearance of aclidinium reported previously, suggest a lower propensity to induce urinary retention in humans than tiotropium and ipratropium.
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Affiliation(s)
- Amadeu Gavaldà
- Almirall S.A., Biology Department, Sant Feliu de Llobregat, Barcelona, Spain.
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