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Han X, Li D, Reyes-Ortega F, Schneider-Futschik EK. Dry Powder Inhalation for Lung Delivery in Cystic Fibrosis. Pharmaceutics 2023; 15:pharmaceutics15051488. [PMID: 37242730 DOI: 10.3390/pharmaceutics15051488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/30/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Pulmonary drug delivery has long been used for local and systemic administration of different medications used in acute and chronic respiratory diseases. Certain lung diseases, such as cystic fibrosis, rely heavily on chronic treatments, including targeted lung delivery. Pulmonary drug delivery possesses various physiological advantages compared to other delivery methods and is also convenient for the patient to use. However, the formulation of dry powder for pulmonary delivery proves challenging due to aerodynamic restrictions and the lower tolerance of the lung. The aim of this review is to provide an overview of the respiratory tract structure in patients with cystic fibrosis, including during acute and chronic lung infections and exacerbations. Furthermore, this review discusses the advantages of targeted lung delivery, including the physicochemical properties of dry powder and factors affecting clinical efficacy. Current inhalable drug treatments and drugs currently under development will also be discussed.
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Affiliation(s)
- Xiaoxuan Han
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Danni Li
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Felisa Reyes-Ortega
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Elena K Schneider-Futschik
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
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Asthma in Cystic Fibrosis: Definitions and Implications of This Overlap Syndrome. Curr Allergy Asthma Rep 2021; 21:9. [PMID: 33560464 DOI: 10.1007/s11882-020-00985-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF) is a multisystem, autosomal recessive disease that leads to progressive loss of lung function. Respiratory symptoms for both CF and asthma include cough, wheezing, and dyspnea. There is debate within the CF community on how to best define and distinguish CF-asthma overlap syndrome (CFAOS) from asthma-like features, though CFAOS is well-recognized. We aim to review the epidemiology, diagnosis, and treatment of asthma in CF and explore areas where further research is needed. RECENT FINDINGS There has been considerable improvement in the understanding and treatment of asthma over the past two decades leading to novel therapies such as biologic agents that target the airway inflammation in asthmatics based on their asthma phenotype. These therapies are being studied in CFAOS and are promising treatments. This review provides a comprehensive overview of the definition, epidemiology, diagnosis, and current treatment of CFAOS.
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Wheatley CM, Baker SE, Daines CM, Phan H, Martinez MG, Morgan WJ, Snyder EM. Influence of the Vibralung Acoustical Percussor on pulmonary function and sputum expectoration in individuals with cystic fibrosis. Ther Adv Respir Dis 2019; 12:1753466618770997. [PMID: 29697011 PMCID: PMC5961921 DOI: 10.1177/1753466618770997] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The Vibralung Acoustical Percussor is a new airway clearance therapy (ACT) utilizing intrapulmonary sound waves in addition to positive expiratory pressure (PEP). We evaluated the safety of the Vibralung and collected preliminary data on its ability to mediate sputum expectoration in individuals with cystic fibrosis (CF). Methods: Over two separate studies, 10 and 11 mild to moderate CF patients were recruited for study I and II, respectively. Study I: Vibralung was used for 20 min with either no sound (NS: PEP only) or sound (S: PEP and sound) on randomized visits. Pulmonary function, diffusion capacity of the lungs for carbon monoxide and nitric oxide (DLCO/DLNO), symptoms, and peripheral oxygen saturation (SpO2) were measured at baseline and at 1 and 4 h post treatment. Expectorated sputum was collected over 4 h post treatment. Study II: over 5 days of in-hospital therapy, the Vibralung or vibratory vest therapy (Vest) were used for two therapy sessions per day, with sputum collected for 20 min following each therapy and pulmonary function accessed pre and post each 5-day period (days 1–5 or 7–11) in a randomized crossover design. Results: Vibralung usage resulted in no change from baseline to 4 h post in pulmonary function, SpO2 or symptoms (p > 0.05). At 4 h post therapy, the DLCO- and DLNO-derived measure of alveolar–capillary unit function (DM/VC) showed improvement (DM/VC = 12.5 ± 5.5 versus 7.3 ± 18.8% change, S versus NS) with no difference between S and NS (p = 0.74). Sputum expectoration was similar between S and NS conditions (wet sputum = 10.5 ± 4.6 versus 9.9 ± 3.2 g, S versus NS, p = 0.25). There were no differences in the improvement in pulmonary function between Vibralung and Vest during either 5-day period during the hospital stay. Conclusions: Vibralung was well tolerated and caused no detrimental changes in pulmonary function metrics. The Vibralung appears to be a safe ACT in individuals with CF.
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Affiliation(s)
- Courtney M Wheatley
- Department of Cardiovascular Diseases, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Sarah E Baker
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Cori M Daines
- Department of Pediatrics-Pediatric Pulmonology and Sleep, University of Arizona, Tucson, AZ, USA Banner-University Medical Center, Tucson, AZ, USA
| | - Hanna Phan
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA Department of Pediatrics-Pediatric Pulmonology and Sleep, University of Arizona, Tucson, AZ, USA
| | - Marina G Martinez
- Arizona Clinical Research Center, University of Arizona, Tucson, AZ, USA
| | - Wayne J Morgan
- Department of Pediatrics-Pediatric Pulmonology and Sleep, University of Arizona, Tucson, AZ, USA Banner-University Medical Center, Tucson, AZ, USA
| | - Eric M Snyder
- Department of Kinesiology, University of Minnesota, Minneapolis, MN, USA; and Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
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Abstract
BACKGROUND Cystic fibrosis is a life-limiting inherited condition which affects one in 2500 newborns in the UK and 70,000 children and adults worldwide. The condition is multifaceted and affects many systems in the body. The respiratory system is particularly affected due to a build up of thickened secretions and a predisposition to infection. Inhaled bronchodilators are prescribed for 80% of people with cystic fibrosis in order to widen the airways and alleviate symptoms. Both short- and long-acting inhaled bronchodilators are used to improve respiratory symptoms. Short-acting inhaled bronchodilators take effect in minutes and typically last for four to eight hours (muscarinic antagonists). Long-acting inhaled bronchodilators also take effect within minutes but typically last for around 12 hours and sometimes longer. This review is one of two which are replacing a previously published review of both long- and short-acting inhaled bronchodilators. OBJECTIVES This review aims to evaluate long-acting inhaled bronchodilators in children and adults with cystic fibrosis in terms of clinical outcomes and safety. If possible, we aimed to assess the optimal drug and dosage regimen. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books.Date of last search: 10 October 2017.We also carried out a separate search of Embase and the reference lists of included trials. We searched clinical trials registries for any ongoing trials and made contact with pharmaceutical companies for any further trials.Date of Embase search: 11 October 2017. SELECTION CRITERIA Randomised or quasi-randomised parallel trials comparing long-acting inhaled bronchodilators (beta-2 agonists and muscarinic antagonists) with placebo, no treatment or a different long-acting inhaled bronchodilator in adults and children with cystic fibrosis. DATA COLLECTION AND ANALYSIS Both authors independently assessed trials for inclusion (based on title, abstract and full text). The authors independently assessed the included trials for quality and risk of bias and extracted data. Discrepancies were resolved by a third party. MAIN RESULTS The searches identified 195 unique references, of which 155 were excluded on title and abstract. We assessed the full texts of the remaining references, excluded 16 trials (28 references) and included four trials (12 references) in the review with 1082 participants.One trial (n = 16) measuring the effect of beta-2 agonists reported an improvement in forced expiratory volume at one second (FEV1) after treatment (at one month), but the trial was small with an unclear risk of bias so we judged the evidence to be very low quality. The trial did not report on participant-reported outcomes, quality of life or adverse events.Three trials (n = 1066) looked at the effects of the muscarinic antagonist tiotropium at doses of 2.5 µg and 5.0 µg in both the short term (up to 28 days) and the longer term (up to three months). Only one of the trials reported the change in FEV1 (L) after 28 days treatment and showed no significant difference between groups; with 2.5 µg tiotropium, mean difference (MD) -0.02 (95% confidence interval (CI) -0.13 to 0.09), or 5.0 µg tiotropium, MD 0.00 (95% CI -0.10 to 0.10) (moderate-quality evidence). All three trials of muscarinic antagonists provided data on adverse events which were found to differ little from placebo at doses of 2.5 µg, risk ratio (RR) 1.01 (95% CI 0.92 to 1.11) or 5.0 µg, RR 0.98 (95% CI 0.90 to 1.06). Very little participant-reported outcome data or quality of life data were available for analysis. Two of the trials were at low risk of bias overall whilst the remaining trial was at an unclear risk overall. AUTHORS' CONCLUSIONS Neither long-acting beta-2 agonists nor long-acting muscarinic antagonist bronchodilators demonstrate improvement in our primary outcome of FEV1. No difference was observed between intervention and placebo in terms of quality of life or adverse events. The quality of evidence for the use of beta-2 agonists was very low. The use of a long-acting inhaled bronchodilator may help to reduce the burden of treatment for people with cystic fibrosis as it is taken less often than a short-acting inhaled bronchodilator, but future trials would benefit from looking at the effects on our primary outcomes (spirometric changes from baseline, quality of life and adverse effects) in the longer term.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, The University of Nottingham, 1701 E Floor, East Block Queens Medical Centre, Nottingham, NG7 2UH, UK
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Affiliation(s)
- Peter J Barry
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester, Manchester, United Kingdom of Great Britain and Northern Ireland
- Institute of Inflammation and Repair, University of Manchester, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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Bradley JM, Koker P, Deng Q, Moroni-Zentgraf P, Ratjen F, Geller DE, Elborn JS. Testing two different doses of tiotropium Respimat® in cystic fibrosis: phase 2 randomized trial results. PLoS One 2014; 9:e106195. [PMID: 25188297 PMCID: PMC4154718 DOI: 10.1371/journal.pone.0106195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 07/25/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tiotropium is a once-daily, long-acting anticholinergic bronchodilator with the potential to alleviate airway obstruction in cystic fibrosis. Our objective was to evaluate the efficacy and safety of 2.5 and 5 µg once-daily tiotropium delivered via the Respimat Soft Mist Inhaler vs. placebo in people with cystic fibrosis. METHODS This phase 2, 12-week, randomized, double-blind, placebo-controlled parallel-group study of tiotropium Respimat as add-on to usual cystic fibrosis maintenance therapy included people with cystic fibrosis with pre-bronchodilator forced expiratory volume in 1 second (FEV1) ≥ 25% predicted. Co-primary efficacy end points were change from baseline in percent-predicted FEV1 area under the curve from 0 to 4 hours (FEV1 AUC0-4h), and trough FEV1 at the end of week 12. FINDINGS A total of 510 subjects with cystic fibrosis aged 5-69 years were randomized. Both doses of tiotropium resulted in significant improvement compared with placebo in the co-primary efficacy end points at the end of week 12 (change from baseline in percent-predicted FEV1 AUC0-4h: 2.5 µg: 2.94%, 95% confidence interval 1.19-4.70, p = 0.001; 5 µg: 3.39%, 95% confidence interval 1.67-5.12, p = 0.0001; in percent-predicted trough FEV1 ∶ 2.5 µg: 2.24%, p = 0.2; 5 µg: 2.22%, p = 0.02). There was a greater benefit with tiotropium 5 vs. 2.5 µg. No treatment-related adverse events or unexpected safety findings were observed in patients taking tiotropium. CONCLUSIONS Tiotropium significantly improved lung function in people with cystic fibrosis. The improvement was greater with the higher dose than the lower dose, with no difference in adverse events. TRIAL REGISTRATION ClinicalTrials.gov NCT00737100 EudraCT 2008-001156-43.
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Affiliation(s)
- Judy M. Bradley
- Institute of Nursing and Health Research, University of Ulster, Ulster, Northern Ireland
| | - Paul Koker
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, United States of America
| | - Qiqi Deng
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, United States of America
| | | | - Felix Ratjen
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David E. Geller
- Florida State University College of Medicine, Orlando, Florida, United States of America
| | - J. Stuart Elborn
- Centre for Infection and Immunity, Queen’s University Belfast, Belfast, Northern Ireland
- * E-mail:
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Kent BD, Lane SJ, van Beek EJ, Dodd JD, Costello RW, Tiddens HAWM. Asthma and cystic fibrosis: a tangled web. Pediatr Pulmonol 2014; 49:205-13. [PMID: 24420817 DOI: 10.1002/ppul.22934] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/06/2013] [Indexed: 01/04/2023]
Abstract
Successfully diagnosing concomitant asthma in people with cystic fibrosis (CF) is a challenging proposition, and the utility of conventional diagnostic criteria of asthma in CF populations remains uncertain. Nonetheless, the accurate identification of individuals with CF and asthma allows appropriate tailoring of therapy, and should reduce the unnecessary use of asthma medication in broader CF cohorts. In this review, we discuss the diagnostic challenge posed by asthma in CF, both in terms of clinical evaluation, and of interpretation of pulmonary function testing and non-invasive markers of airway inflammation. We also examine how the role of cross-sectional thoracic imaging in CF and asthma can assist in the diagnosis of asthma in these patients. Finally, we critically appraise the evidence base behind the use of asthma medications in CF populations, with a particular focus on the use of inhaled corticosteroids and bronchodilators. As shall be discussed, the gaps in the current literature make further high-quality research in this field imperative.
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Affiliation(s)
- Brian D Kent
- Department of Respiratory Medicine, Adelaide & Meath Hospital, Dublin, Ireland
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8
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Inhaled medication and inhalation devices for lung disease in patients with cystic fibrosis: A European consensus. J Cyst Fibros 2009; 8:295-315. [DOI: 10.1016/j.jcf.2009.04.005] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 04/05/2009] [Accepted: 04/08/2009] [Indexed: 12/12/2022]
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Flume PA, O'Sullivan BP, Robinson KA, Goss CH, Mogayzel PJ, Willey-Courand DB, Bujan J, Finder J, Lester M, Quittell L, Rosenblatt R, Vender RL, Hazle L, Sabadosa K, Marshall B. Cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung health. Am J Respir Crit Care Med 2007; 176:957-69. [PMID: 17761616 DOI: 10.1164/rccm.200705-664oc] [Citation(s) in RCA: 442] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
RATIONALE Cystic fibrosis is a recessive genetic disease characterized by dehydration of the airway surface liquid and impaired mucociliary clearance. As a result, individuals with the disease have difficulty clearing pathogens from the lung and experience chronic pulmonary infections and inflammation. Death is usually a result of respiratory failure. Newly introduced therapies and aggressive management of the lung disease have resulted in great improvements in length and quality of life, with the result that the median expected survival age has reached 36 years. However, as the number of treatments expands, the medical regimen becomes increasingly burdensome in time, money, and health resources. Hence, it is important that treatments should be recommended on the basis of available evidence of efficacy and safety. OBJECTIVES The Cystic Fibrosis Foundation therefore established a committee to examine the clinical evidence for each therapy and to provide guidance for the prescription of these therapies. METHODS The committee members developed and refined a series of questions related to drug therapies used in the maintenance of pulmonary function. We addressed the questions in one of three ways, based on available evidence: (1) commissioned systematic review, (2) modified systematic review, or (3) summary of existing Cochrane reviews. CONCLUSIONS It is hoped that the guidelines provided in this article will facilitate the appropriate application of these treatments to improve and extend the lives of all individuals with cystic fibrosis.
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Affiliation(s)
- Patrick A Flume
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Yankaskas JR, Marshall BC, Sufian B, Simon RH, Rodman D. Cystic fibrosis adult care: consensus conference report. Chest 2004; 125:1S-39S. [PMID: 14734689 DOI: 10.1378/chest.125.1_suppl.1s] [Citation(s) in RCA: 354] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Le Roux P, Le Luyer B. Traitements inhales bronchodilatateurs et fluidifiants dans la mucoviscidose. Arch Pediatr 2003; 10 Suppl 2:358s-363s. [PMID: 14671935 DOI: 10.1016/s0929-693x(03)90053-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Poor clearance of airway secretions contributes to the pulmonary disease in cystic fibrosis (CF). Bronchodilator therapy might benefit in CF, but the efficacy is controversial. Effects of mucolytic agents have not been demonstrated conclusively. Only, efficacy of recombinant human deoxyribonuclease (rhDNase) is established with a rapid onset of benefit.
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Affiliation(s)
- P Le Roux
- Centre de ressources et de compétence dans la mucoviscidose, département de pédiatrie, groupe hospitalier, 55 bis, rue Gustave-Flaubert, 76600 Le Havre, France.
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12
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Jaffe A, Balfour-Lynn IM. Treatment of severe small airways disease in children with cystic fibrosis: alternatives to corticosteroids. Paediatr Drugs 2002; 4:381-9. [PMID: 12038874 DOI: 10.2165/00128072-200204060-00005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
A group of patients with cystic fibrosis (CF) have severe small airways disease characterized by wheeze, chest tightness and limited sputum production, often with deteriorating lung function. Suggested mechanisms include mucosal edema secondary to infection and inflammation, smooth muscle contraction caused by inflammatory mediators, and collapse of bronchiectatic airways. While treatment with long-term oral corticosteroids may result in symptomatic improvement, adverse effects often make them intolerable. Inhaled corticosteroids are used in many centers despite the lack of conclusive evidence of their efficacy. Therapeutic alternatives to corticosteroids are aimed at reversing bronchoconstriction and reducing inflammation. Many patients with CF are treated with short- and long-term inhaled bronchodilators, but data to support their use are inconclusive. Other attempted routes of administration for short-acting bronchodilators include the subcutaneous and intravenous routes, but clinical data are again lacking. Sodium cromoglycate (cromolyn sodium) has been studied, with little evidence of benefit. Theophyllines have also been studied, both intravenously and orally, with some effect, but are not often used in clinical practice. Nonsteroidal anti-inflammatory therapies include ibuprofen, macrolide antibiotics, intravenous immunoglobulin, cyclosporine, and leukotriene antagonists. Ibuprofen has been shown to be useful in patients with mild CF disease, but concerns about potential adverse effects have limited its use. The results of various macrolide studies are awaited, but to date there are no long-term studies published. While there is great interest in the potential of intravenous immunoglobulin, cyclosporine and leukotriene antagonists, the evidence for their effectiveness comes from anecdotal reports, thus there is currently insufficient data to support their use. Since this is a small group of patients, it is unlikely that sufficient numbers will ever be recruited for these studies; thus it is probable that drugs will be tried on an individual patient basis. The order in which they are attempted is unclear, but it would be sensible to try the least invasive medication with the least adverse effects first, moving on to more potent, but more toxic drugs if that treatment fails.
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Affiliation(s)
- Adam Jaffe
- Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
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Hordvik NL, Sammut PH, Judy CG, Colombo JL. Effectiveness and tolerability of high-dose salmeterol in cystic fibrosis. Pediatr Pulmonol 2002; 34:287-96. [PMID: 12205570 DOI: 10.1002/ppul.10162] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The efficacy and tolerability of high-dose salmeterol (100 mcg, BID) and albuterol (2.5 mg, BID) were compared with those of albuterol (2.5 mg, BID) in outpatients with cystic fibrosis in a randomized, double-blind, double-dummy, placebo-controlled, crossover study with both short- (4 weeks of each) and long-term (24 weeks of each) treatment periods. The primary outcome measure was the difference in mean change in forced expired volume in 1 sec (FEV(1)) from baseline to the end of each treatment, and secondary measures included changes in forced vital capacity (FVC), forced expiratory flow between 25-75% of FVC (FEF(25-75)), patient-rated weekly symptom scores, number of extra (rescue) albuterol treatments, and number of antibiotic treatments. Tolerability was evaluated by changes in vital signs and adverse events.Thirty-six out of 44 patients enrolled finished the short-term treatment period, and 19 out of 23 who continued the study also finished the long-term treatment period. There was no significant difference in the mean % change in FEV(1) from baseline to completion of 4 weeks with each drug in the short-term treatment period (0.1% vs. 0.06%, albuterol vs. salmeterol; respectively). In the long-term treatment period, there was a significant decrease from baseline in FEV(1) with albuterol vs. salmeterol, as measured after both 12 and 24 weeks of each treatment (-6.2% vs. 1.8%, P = 0.013 after 12 weeks, and -6.5% vs. 1.7%, P = 0.002, after 24 weeks, respectively). In both treatment periods, salmeterol was well-tolerated. While there were more rescue treatments per patient per week with albuterol than with salmeterol treatment in both the short- and long-term periods (0.67 vs. 0.40 and 1.76 vs. 0.74, respectively), rescue treatments were needed significantly more often for only the long-term period with albuterol compared to salmeterol (P = 0.022). Also, there were more antibiotic interventions with albuterol than with salmeterol treatment in both the short- and long-term periods (25 vs. 10 and 56 vs. 42, respectively); however, antibiotics were needed significantly more often for only the short-term period (P = 0.011). In addition, there was a significantly higher symptom score with albuterol vs. salmeterol treatment during the second half of the long-term period (1.24 vs. 0.89, P = 0.001).In conclusion, long-term high-dose salmeterol was equally safe and was associated with better pulmonary function, fewer interventions, and fewer respiratory symptoms compared to standard therapy with albuterol in a population of outpatients with mild to moderate CF.
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Affiliation(s)
- Nancy L Hordvik
- Department of Pediatric Pulmonology, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
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14
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Abstract
Airways reactivity, hyper-reactivity, and hyper-responsiveness are terms used to describe airways for which there appears to be increased bronchial smooth muscle tone or responsiveness. Some patients with cystic fibrosis (CF) have concomitant asthma causing airway hyperresponsiveness as manifested by recurrent acute symptoms of dyspnea that is impressively responsive to an inhaled beta 2 agonist and/or systemic corticosteroids. However, many others have a degree of bronchodilator responsiveness in the absence of an impressive clinical response to such anti-asthmatic treatment. In contrast to those with asthma, exercise does not induce bronchospasm and can even cause bronchodilatation in patients with CF who have bronchodilator responsiveness in the absence of asthma. The airway hyperresponsiveness of CF also differs in its response to histamine induced bronchospasm which is effectively reversed with ipratropium in patients with CF who symptomatically do not have asthma, whereas ipratropium does not adequately reverse histamine-induced bronchospasm in those with concomitant symptoms of asthma. These and other data suggest that the increased airway reactivity in patients with CF is vagally mediated and results from the airway damage caused by the lung disease. The use of bronchodilators as a routine part of CF lung disease care is controversial, but there is little evidence that treating airway reactivity in patients with CF is of clinical importance as a routine measure in the absence of clinical asthma. Definite subjective improvement in symptoms or improved sputum production when a bronchodilator precedes chest physical therapy should be sought to justify continued use in individual patients.
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Affiliation(s)
- Miles Weinberger
- Pediatric Allergy & Pulmonary Division, University of Iowa College of Medicine, Iowa City, IA 52242, USA
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Abstract
The diagnosis of "CF asthma" is problematic and it is difficult to determine which patients have a combination of CF and asthma and which have asthma like symptoms caused by inflammation of the CF lung. This may not matter, however; the relevance lies in the possible approaches to treatment.
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Affiliation(s)
- I M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton & Harefield NHS Trust, London SW3 6NP, UK.
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Salvatore D, D'Andria M. Effects of salmeterol on arterial oxyhemoglobin saturations in patients with cystic fibrosis. Pediatr Pulmonol 2002; 34:11-5. [PMID: 12112791 DOI: 10.1002/ppul.10117] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sleep-related oxygen desaturation has been described in patients with cystic fibrosis (CF). Thus we studied the effects of inhaled Salmeterol xinafoate, a long-acting beta-2 agonist, on transcutaneous oxyhemoglobin saturation in sleeping, stable CF patients. Patients with stable CF (n = 23) were divided into responders and nonresponders to beta-2 agonists, based on an albuterol challenge during daytime testing, and then they received salmeterol before sleep, in a double-blind crossover design. Overnight oxyhemoglobin saturation measurements and spirometry on awakening were performed. Salmeterol administration before sleep resulted in statistically significant increases in mean arterial oxyhemoglobin saturation and in FEV(1) and FEF(25-75) on awakening compared to placebo values, but only in patients responding to daytime albuterol inhalation by showing improvement in lung function. We conclude that salmeterol inhalation at bedtime could prevent or reduce nocturnal hypoxemia in daytime albuterol-responsive CF patients, thus improving the long-term clinical outcome of CF lung disease.
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Affiliation(s)
- Donatello Salvatore
- Pediatric Division, Cystic Fibrosis Center, San Carlo Hospital, Potenza, Italy.
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17
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Shrewsbury S, Hallett C. Salmeterol 100 microg: an analysis of its tolerability in single- and chronic-dose studies. Ann Allergy Asthma Immunol 2001; 87:465-73. [PMID: 11770693 DOI: 10.1016/s1081-1206(10)62259-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND A combination product containing fluticasone propionate 100 or 250 microg and salmeterol 50 microg has recently been made available in the United States. Some patients, if previously instructed to double their inhaled corticosteroids, may double this product, inadvertently receiving higher doses of salmeterol, potentially causing systemic beta2-agonist-related effects. OBJECTIVES To examine the systemic effects of single and chronic doses of salmeterol 100 microg. METHODS Forty-four studies including a salmeterol 100 microg treatment arm were identified. Data on predictable systemic effects were available in 10 single-dose and 9 chronic-dose studies lasting more than 7 days, in patients with asthma (6 adult, 2 pediatric) or chronic obstructive pulmonary disease (1 study), which were included in a weighted, pooled analysis. RESULTS Single 100-microg dose studies: mean change from baseline in heart rate was +2.3 beats per minute and systolic blood pressure +0.4 mm Hg. Tremor and palpitations were reported in 5.7% and 2.8%. Other systemic effects included a decrease in serum potassium for 3 subjects (2.1%); an increase in serum glucose, 1 subject (0.7%); and electrocardiographic (ECG) events, 24 cases (17.0%). Twenty-three of these were from one crossover study which reported 27 ECG events after placebo. Chronic dose studies (salmeterol 100 microg): mean change in heart rate and systolic blood pressure were +1.8 beats per minute and -0.2 mm Hg. Tremor and palpitations were reported in 5.6% and 1.7% of 1,504 patients. Thirteen recorded a decrease in serum potassium (0.9%) and 5 an increase in serum glucose (0.3%). Nine patients had ECG events (0.6%). Eight of these were "arrhythmia" from one study, which also reported 12 events before treatment. CONCLUSIONS The mean systemic effects of salmeterol 100 microg are small and of doubtful clinical relevance. Patients (and their caregivers) can be reassured that inadvertently taking double doses of the new combination product are unlikely to affect them adversely.
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Affiliation(s)
- S Shrewsbury
- GlaxoSmithKline UK Limited, Uxbridge, Middlesex, United Kingdom.
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