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Green S. Climate-conscious inhaler prescribing for family physicians. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2024; 70:381-387. [PMID: 38886092 PMCID: PMC11280715 DOI: 10.46747/cfp.7006381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVE To provide family physicians with prescribing and diagnostic strategies that can reduce carbon emissions associated with inhalers. SOURCES OF INFORMATION This review is based on the authors' experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed. MAIN MESSAGE There is growing acknowledgment of the substantial impact that inhalers have on climate emissions generated by the health sector. Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available. Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care and enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions. Family physicians may reduce carbon emissions associated with inhalers by reducing unnecessary inhaler prescribing; ensuring patients' control of asthma and COPD is optimized; considering whether a more sustainable inhaler may be appropriate; optimizing dosing technique to reduce emissions and waste; and disposing of inhalers appropriately if possible. CONCLUSION Family physicians may reduce carbon emissions associated with inhalers through the following strategies: confirming diagnosis, controlling disease, considering inhaler type, optimizing dosing technique, and encouraging appropriate disposal.
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Affiliation(s)
- Samantha Green
- Family physician at Unity Health in Toronto, Ont, and Assistant Professor at the University of Toronto
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2
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Liang K, Hui P, Green S. Toux postinfectieuse chez les adultes. CMAJ 2024; 196:E679-E680. [PMID: 38772603 PMCID: PMC11104575 DOI: 10.1503/cmaj.231523-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024] Open
Affiliation(s)
- Kevin Liang
- Département de médecine de famille, Faculté de médecine (Liang), Université de la Colombie-Britannique, Vancouver, C.-B.; Autorité sanitaire Fraser (Liang, Hui), Surrey, C.-B.; Division de pneumologie, Département de médecine, Faculté de médecine (Hui), Université de la Colombie-Britannique, Vancouver, C.-B.; Équipe universitaire de santé familiale (Green), Hôpital St. Michael, Université de Toronto, Toronto, Ont.
| | - Philip Hui
- Département de médecine de famille, Faculté de médecine (Liang), Université de la Colombie-Britannique, Vancouver, C.-B.; Autorité sanitaire Fraser (Liang, Hui), Surrey, C.-B.; Division de pneumologie, Département de médecine, Faculté de médecine (Hui), Université de la Colombie-Britannique, Vancouver, C.-B.; Équipe universitaire de santé familiale (Green), Hôpital St. Michael, Université de Toronto, Toronto, Ont
| | - Samantha Green
- Département de médecine de famille, Faculté de médecine (Liang), Université de la Colombie-Britannique, Vancouver, C.-B.; Autorité sanitaire Fraser (Liang, Hui), Surrey, C.-B.; Division de pneumologie, Département de médecine, Faculté de médecine (Hui), Université de la Colombie-Britannique, Vancouver, C.-B.; Équipe universitaire de santé familiale (Green), Hôpital St. Michael, Université de Toronto, Toronto, Ont
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3
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Liang K, Hui P, Green S. Postinfectious cough in adults. CMAJ 2024; 196:E157. [PMID: 38346782 PMCID: PMC10861265 DOI: 10.1503/cmaj.231523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Affiliation(s)
- Kevin Liang
- Department of Family Medicine, Faculty of Medicine (Liang), University of British Columbia, Vancouver, BC; Fraser Health Authority (Liang, Hui), Surrey, BC; Division of Respiratory Medicine, Department of Medicine, Faculty of Medicine (Hui), University of British Columbia, Vancouver, BC; St. Michael's Hospital Academic Family Health Team (Green), University of Toronto, Toronto, Ont.
| | - Philip Hui
- Department of Family Medicine, Faculty of Medicine (Liang), University of British Columbia, Vancouver, BC; Fraser Health Authority (Liang, Hui), Surrey, BC; Division of Respiratory Medicine, Department of Medicine, Faculty of Medicine (Hui), University of British Columbia, Vancouver, BC; St. Michael's Hospital Academic Family Health Team (Green), University of Toronto, Toronto, Ont
| | - Samantha Green
- Department of Family Medicine, Faculty of Medicine (Liang), University of British Columbia, Vancouver, BC; Fraser Health Authority (Liang, Hui), Surrey, BC; Division of Respiratory Medicine, Department of Medicine, Faculty of Medicine (Hui), University of British Columbia, Vancouver, BC; St. Michael's Hospital Academic Family Health Team (Green), University of Toronto, Toronto, Ont
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4
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Shao W, Luo X, Zhang Z, Han Z, Chandrasekaran V, Turzhitsky V, Bali V, Roberts AR, Metzger M, Baker J, La Rosa C, Weaver J, Dexter P, Huang K. Application of unsupervised deep learning algorithms for identification of specific clusters of chronic cough patients from EMR data. BMC Bioinformatics 2022; 23:140. [PMID: 35439945 PMCID: PMC9019947 DOI: 10.1186/s12859-022-04680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic cough affects approximately 10% of adults. The lack of ICD codes for chronic cough makes it challenging to apply supervised learning methods to predict the characteristics of chronic cough patients, thereby requiring the identification of chronic cough patients by other mechanisms. We developed a deep clustering algorithm with auto-encoder embedding (DCAE) to identify clusters of chronic cough patients based on data from a large cohort of 264,146 patients from the Electronic Medical Records (EMR) system. We constructed features using the diagnosis within the EMR, then built a clustering-oriented loss function directly on embedded features of the deep autoencoder to jointly perform feature refinement and cluster assignment. Lastly, we performed statistical analysis on the identified clusters to characterize the chronic cough patients compared to the non-chronic cough patients. RESULTS The experimental results show that the DCAE model generated three chronic cough clusters and one non-chronic cough patient cluster. We found various diagnoses, medications, and lab tests highly associated with chronic cough patients by comparing the chronic cough cluster with the non-chronic cough cluster. Comparison of chronic cough clusters demonstrated that certain combinations of medications and diagnoses characterize some chronic cough clusters. CONCLUSIONS To the best of our knowledge, this study is the first to test the potential of unsupervised deep learning methods for chronic cough investigation, which also shows a great advantage over existing algorithms for patient data clustering.
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Affiliation(s)
- Wei Shao
- Indiana University School of Medicine, 1101 W 10th Street, Indianapolis, IN, 46202, USA
| | - Xiao Luo
- Purdue School of Engineering and Technology, IUPUI, ET 301L, 799 W. Michigan Street, Indianapolis, IN, 46202, USA.
| | - Zuoyi Zhang
- Indiana University School of Medicine, 1101 W 10th Street, Indianapolis, IN, 46202, USA
| | - Zhi Han
- Indiana University School of Medicine, 1101 W 10th Street, Indianapolis, IN, 46202, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Vasu Chandrasekaran
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Vladimir Turzhitsky
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Vishal Bali
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
| | | | | | - Jarod Baker
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Carmen La Rosa
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Jessica Weaver
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Paul Dexter
- Indiana University School of Medicine, 1101 W 10th Street, Indianapolis, IN, 46202, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Eskenazi Health, Indianapolis, IN, USA
| | - Kun Huang
- Indiana University School of Medicine, 1101 W 10th Street, Indianapolis, IN, 46202, USA. .,Regenstrief Institute, Inc., Indianapolis, IN, USA.
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5
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Merlo C, Essig S, Brancati-Badarau DO, Leuppi JD, Speich B, Erlanger TE, Hemkens LG, Zeller A. Oral corticosteroids for post-infectious cough in adults: study protocol for a double-blind randomized placebo-controlled trial in Swiss family practices (OSPIC trial). Trials 2020; 21:949. [PMID: 33225983 PMCID: PMC7681763 DOI: 10.1186/s13063-020-04848-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cough is a common reason for patients to visit general practices. So-called post-infectious cough is defined as lasting 3 to 8 weeks after an upper respiratory tract infection. It can be disabling in daily activities, with substantial impact on physical and psychosocial health, leading to impaired quality of life and increased health care costs. Recommendations for the management of post-infectious cough in primary care are scarce and incoherent. A systematic review and meta-analysis of randomized clinical trials (RCT) assessing patient-relevant benefits and potential harms of available treatments identified six eligible RCTs assessing different treatment regimens (i.e. inhaled fluticasone propionate, inhaled budesonide, salbutamol plus ipratropium-bromide, montelukast, nociception-opioid-1-receptor agonist, codeine, gelatine). No RCT found clear patient-relevant benefits and most had an unclear or high risk of bias. Post-infectious cough is thought to be mediated by inflammatory processes that are also present in exacerbations of asthma or chronic obstructive pulmonary diseases for which there is strong evidence that oral corticosteroids provide patient-relevant benefit without relevant harm. We therefore plan to conduct the first RCT evaluating the effectiveness of oral corticosteroids for post-infectious cough. METHODS We are conducting a triple-blinded randomized-controlled and multicentred superiority trial in primary health care practices in Switzerland. We will include 204 adult patients who consult their general practitioner (GP) for a cough lasting 3 to 8 weeks following an upper respiratory tract infection. Participants will be randomly allocated to either the 5-day treatment with oral corticosteroids or placebo. The primary outcome is cough-related quality of life assessed by the Leicester Cough Questionnaire score 14 days after randomization. Secondary outcomes include cough-related quality of life at several time points, overall cessation of cough and adverse events. DISCUSSION This RCT will provide evidence on whether oral corticosteroids are beneficial and safe in patients with post-infectious cough. Results can have a substantial impact on the well-being and management of these patients in Switzerland and beyond. An evidence-based treatment for this condition may reduce re-consultations with GPs and spending for antitussive drugs, thus possibly having an impact on health care spending. TRIAL REGISTRATION ClinicalTrials.gov NCT04232449 . Prospectively registered on 18 January 2020.
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Affiliation(s)
- Christoph Merlo
- Institute of Primary and Community Care, Lucerne, Switzerland
| | - Stefan Essig
- Institute of Primary and Community Care, Lucerne, Switzerland
| | | | - Jörg Daniel Leuppi
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.,University of Basel, Basel, Switzerland
| | - Benjamin Speich
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, and University of Basel, Basel, Switzerland.,Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Tobias E Erlanger
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, and University of Basel, Basel, Switzerland.,Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany.,Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland.
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6
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Chang RYK, Kwok PCL, Ghassabian S, Brannan JD, Koskela HO, Chan H. Cough as an adverse effect on inhalation pharmaceutical products. Br J Pharmacol 2020; 177:4096-4112. [PMID: 32668011 PMCID: PMC7443471 DOI: 10.1111/bph.15197] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 01/06/2023] Open
Abstract
Cough is an adverse effect that may hinder the delivery of drugs into the lungs. Chemical or mechanical stimulants activate the transient receptor potential in some airway afferent nerves (C-fibres or A-fibres) to trigger cough. Types of inhaler device and drug, dose, excipients and formulation characteristics, including pH, tonicity, aerosol output and particle size may trigger cough by stimulating the cough receptors. Release of inflammatory mediators may increase the sensitivity of the cough receptors to stimulants. The cough-provoking effect of aerosols is enhanced by bronchoconstriction in diseased airways and reduces drug deposition in the target pulmonary regions. In this article, we review the factors by which inhalation products may cause cough.
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Affiliation(s)
- Rachel Yoon Kyung Chang
- Advanced Drug Delivery Group, Sydney Pharmacy School, Faculty of Medicine and HealthThe University of SydneyCamperdownNSWAustralia
| | - Philip Chi Lip Kwok
- Advanced Drug Delivery Group, Sydney Pharmacy School, Faculty of Medicine and HealthThe University of SydneyCamperdownNSWAustralia
| | - Sussan Ghassabian
- Advanced Drug Delivery Group, Sydney Pharmacy School, Faculty of Medicine and HealthThe University of SydneyCamperdownNSWAustralia
| | - John D. Brannan
- Department of Respiratory and Sleep MedicineJohn Hunter HospitalNewcastleNSWAustralia
| | - Heikki O. Koskela
- Unit for Medicine and Clinical Research, Pulmonary DivisionKuopio University HospitalKuopioFinland
- School of Medicine, Faculty of Health SciencesUniversity of Eastern FinlandKuopioFinland
| | - Hak‐Kim Chan
- Advanced Drug Delivery Group, Sydney Pharmacy School, Faculty of Medicine and HealthThe University of SydneyCamperdownNSWAustralia
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7
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Abstract
Chronic cough is common and impactful, frustrating both patients and clinicians. An empirical trial of therapy is often done with inhaled corticosteroids, but this practice should be replaced with attempting to make an accurate diagnosis. The three most common causes are upper airway cough syndrome, asthma, and gastroesophageal reflux disease (GERD), but there are often multiple causes involved. Minimal investigations after history, physical exam, travel history, and drug history include a chest radiograph and spirometry. Empirical trial of therapy with inhaled corticosteroids is reasonable if there is evidence of eosinophilic inflammation. Empiric therapy for GERD may also be reasonable in those with symptoms. Red flags should especially be considered an urgency to make the correct diagnosis.
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8
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Lee SE, Lee JH, Kim HJ, Lee BJ, Cho SH, Price D, Morice AH, Song WJ. Inhaled Corticosteroids and Placebo Treatment Effects in Adult Patients With Cough: A Systematic Review and Meta-analysis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2019; 11:856-870. [PMID: 31552720 PMCID: PMC6761077 DOI: 10.4168/aair.2019.11.6.856] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/01/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Inhaled corticosteroids (ICSs) are often considered an empirical therapy in the management of patients with cough. However, ICS responsiveness is difficult to interpret in daily clinical practice, as the improvements may include placebo effects or self-remission. We aimed to evaluate ICS and placebo treatment effects in adult patients with cough. METHODS Electronic databases were searched for studies published until June 2018, without language restriction. Randomized controlled trials reporting the effects of ICSs compared with placebo in adult patients with cough were included. Random effects meta-analyses were conducted to estimate the treatment effects. Therapeutic gain was calculated by subtracting the percentage change from baseline in the cough score in the ICS treatment group from that in the placebo treatment group. RESULTS A total of 9 studies were identified and 8 studies measuring cough severity outcomes were included for meta-analyses. Therapeutic gain from ICSs ranged from -5.0% to +94.6% across the studies included; however, it did not exceed +22%, except for an outlier reporting very high therapeutic gains (+45.6% to +94.6%, depending on outcomes). Overall ICS treatment effects in cough severity outcomes were small-to-moderate (standardized mean difference [SMD], -0.38; 95% confidence interval [CI], -0.54, -0.23), which were comparable between subacute and chronic coughs. However, pooled placebo treatment effects were very large in subacute cough (SMD, -2.58; 95% CI, -3.03, -2.1), and modest but significant in chronic cough (SMD, -0.46; 95% CI, -0.72, -0.21). CONCLUSIONS Overall therapeutic gain from ICSs is small-to-moderate. However, placebo treatment effects of ICS are large in subacute cough, and modest but still significant in chronic cough. These findings indicate the need for careful interpretation of ICS responsiveness in the management of cough patients in the clinic, and also for rigorous patient selection to identify ICS-responders.
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Affiliation(s)
- Seung Eun Lee
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ji Hyang Lee
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Byung Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Heon Cho
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - David Price
- Optimum Patient Care, Cambridge, United Kingdom; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Alyn H Morice
- Centre for Cardiovascular and Metabolic Research, Hull York Medical School, Castle Hill Hospital, University of Hull, Cottingham, East Yorkshire, United Kingdom
| | - Woo Jung Song
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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9
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Lai K, Shen H, Zhou X, Qiu Z, Cai S, Huang K, Wang Q, Wang C, Lin J, Hao C, Kong L, Zhang S, Chen Y, Luo W, Jiang M, Xie J, Zhong N. Clinical Practice Guidelines for Diagnosis and Management of Cough-Chinese Thoracic Society (CTS) Asthma Consortium. J Thorac Dis 2018; 10:6314-6351. [PMID: 30622806 PMCID: PMC6297434 DOI: 10.21037/jtd.2018.09.153] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 09/10/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Kefang Lai
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Huahao Shen
- The Second Hospital Affiliated to Medical College of Zhejiang University, Hangzhou 310009, China
| | - Xin Zhou
- Shanghai Jiaotong University Affiliated Shanghai No. 1 People’s Hospital, Shanghai 200080, China
| | - Zhongmin Qiu
- Tongji Affiliated Tongji Hospital, Shanghai 200065, China
| | - Shaoxi Cai
- Southern Medical University Affiliated Nanfang Hospital, Guangzhou 510515, China
| | - Kewu Huang
- Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing 100020, China
| | | | - Changzheng Wang
- Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Jiangtao Lin
- China-Japan Friendship Hospital, Beijing 100029, China
| | - Chuangli Hao
- Children’s Hospital of Soochow University, Suzhou 215025, China
| | - Lingfei Kong
- The First Hospital of China Medical University, Shenyang 110001, China
| | - Shunan Zhang
- China-Japan Friendship Hospital, Beijing 100029, China
| | - Yaolong Chen
- Evidence-based Medical Center of Lanzhou University, Lanzhou 730000, China
| | - Wei Luo
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Jiaxing Xie
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Nanshan Zhong
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
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10
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Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials. Br J Gen Pract 2018; 68:e694-e702. [PMID: 30201828 DOI: 10.3399/bjgp18x698885] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/11/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Subacute cough following a non-specific viral infection lasting 3-8 weeks is common. However, despite many treatment options there are no systematic reviews evaluating these. AIM To provide a systematic overview of treatment options and outcomes evaluated in randomised clinical trials (RCTs). DESIGN AND SETTING Systematic review and meta-analyses assessing the overall effects of any treatment for subacute cough. METHOD The authors systematically searched PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (last search March 2017) for RCTs in adult patients with subacute cough. The authors considered trials evaluating any outcome of any drug or non-drug treatments, apart from traditional Chinese and Asian medicines. They combined treatment effects on cough-related outcomes in random effects meta-analyses. RESULTS Six eligible RCTs including 724 patients were identified. These assessed montelukast, salbutamol plus ipratropium bromide, gelatine, fluticasone propionate, budesonide, and nociception opioid 1 receptor agonist and codeine. Five studies reported effects on various cough severity scores at various timepoints. No treatment option was associated with a clear benefit on cough recovery or other patient-relevant outcomes in any of the studies or in meta-analyses for cough outcomes at 14 days and 28 days. Reported adverse events were rather mild and reported for 14% of patients across all treatments. CONCLUSION Evidence on treatment options for subacute cough is weak. There is no treatment showing clear patient-relevant benefits in clinical trials.
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11
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Abstract
Chronic cough is common and has a significant impact on the wellbeing of patients and the use and cost of health care services. Traditionally the approach to chronic cough in patients who are nonsmokers and are not taking an angiotensin-converting enzyme inhibitor has focused on the diagnosis and management of the upper airway cough syndrome, asthma, and reflux disease. The evaluation of patients with chronic cough frequently involves trials of empiric therapy for these 3 conditions. Chronic cough may be perpetuated by abnormalities of the cough reflex and sensitization of its afferent and central components.
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Affiliation(s)
- Andreas Achilleos
- Internal Medicine Residency Program, Internal Medicine, Hershey Medical Center, 35 Hope Drive, Suite 104, Hershey, PA 17033, USA.
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12
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Kim KI, Shin S, Lee N, Lee BJ, Lee J, Lee H. A traditional herbal medication, Maekmoondong-tang, for cough: A systematic review and meta-analysis. JOURNAL OF ETHNOPHARMACOLOGY 2016; 178:144-154. [PMID: 26666732 DOI: 10.1016/j.jep.2015.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/26/2015] [Accepted: 12/04/2015] [Indexed: 06/05/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Maekmoondong-tang (MMDT) is a traditional herbal medication widely used to improve cough in Korea, Japan, and China. It is composed of six herbs (Ophiopogonis Tuber, Pinelliae Tuber, Glycyrrhizae Radix, Zizyphi Fructus, Ginseng Radix, and Oryzae Semen). AIM OF THE STUDY This study is aimed to systematically review the relevant randomised controlled trials (RCTs) to determine the effectiveness and safety of MMDT for cough. MATERIALS AND METHODS Electronic and hand-searching of 7 databases (Cochrane Library, MEDLINE, EMBASE, OASIS, RISS, CNKI and CiNii) was systematically conducted up to February 2015 for RCTs testing MMDT in patients with cough. The primary outcome was cough symptom improvement using cough diary, visual analog scale, or response rate. Risk of bias of the included trials was evaluated with the Cochrane risk of bias assessment tool. The dichotomous data were pooled to obtain a risk ratio (RR) of cough persisting after treatment, with 95% confidence intervals (CI). RESULTS Nine RCTs involving 2453 participants were included. The methodological quality was largely poor for a majority of the studies. MMDT reduced the severity of cough by 74% compared with the conventional antitussive medications in various conditions (n=1145; RR of cough persisting after treatment=0.26; 95% CI, 0.19-0.34, I(2)=0%). The addition of MMDT to conventional medication in patients with postinfectious cough significantly alleviated symptoms up to day 5 but the effect was not maintained one week afterwards. For other diseases/conditions including chronic obstructive pulmonary disease, lung cancer surgery, and asthma, the evidence is inconsistent for MMDT/mMMDT for cough. Adverse events appear to be rare but the reporting was poor. CONCLUSIONS The current evidence from our systematic review and meta-analysis on MMDT for cough is inconclusive and we propose that rigorously designed, placebo-controlled trials of MMDT should be conducted to establish its place in management of cough.
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Affiliation(s)
- Kwan-Il Kim
- Department of Clinical Korean Medicine, College of Korean Medicine, Kyung Hee University, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-872, Republic of Korea.
| | - Seungwon Shin
- College of Korean Medicine, Kyung Hee University, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-872, Republic of Korea.
| | - Nara Lee
- Graduate School of Public Health, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 151-742, Republic of Korea.
| | - Beom-Joon Lee
- Division of Allergy, Immune and Respiratory System, Department of Internal Medicine, College of Korean Medicine, Kyung Hee University, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-872, Republic of Korea.
| | - Junhee Lee
- College of Korean Medicine, Kyung Hee University, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-872, Republic of Korea.
| | - Hyangsook Lee
- Acupuncture & Meridian Science Research Centre, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-701, Republic of Korea.
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13
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Kim KI, Shin S, Kim K, Lee J. Efficacy and safety of Maekmoondong-tang for chronic dry cough: a study protocol for a randomized controlled trial. Altern Ther Health Med 2016; 16:46. [PMID: 26829923 PMCID: PMC4736174 DOI: 10.1186/s12906-016-1028-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/27/2016] [Indexed: 12/20/2022]
Abstract
Background Chronic cough, defined it lasts more than 8 weeks. The symptom is common, but highly troublesome, and it reduces quality of life. Despite much effort to develop a protocol for diagnosis and treatment of chronic cough, it remains problematic to determine its cause. As a result, treatment is often unsuccessful. Thus, there is much interest regarding the use of symptomatic drugs to control chronic cough. Maekmoondong-tang is widely used in East Asian countries to treat chronic dry cough. Several experimental studies have reported that the herbal medicine has immunomodulatory and antitussive effects. Clinical studies involving Maekmoondong-tang have also been carried out; however, these studies have involved treating various diseases as a whole rather than chronic cough itself. Thus, we aim to evaluate the efficacy and safety of Maekmoondong-tang in chronic dry cough patients with a randomized controlled trial. Methods/Design This study is designed as an exploratory, single-center, placebo-controlled, double-blind, randomized, parallel group clinical trial. Patients with dry cough that has lasted more than 8 weeks will be recruited, after a 1-week run-in period, and randomly allocated to either the Maekmoondong-tang treatment group or the placebo group. The patients will receive Maekmoondong-tang or placebo granules 3 times daily for 4 weeks, with a 2-week follow-up. The primary outcome is a 10-point cough diary that will be recorded on a daily basis. The secondary outcomes comprise a cough visual analog scale, the Leicester Cough Questionnaire (Korean version), the Pattern Identification for Chronic Cough Questionnaire, biomarkers, safety testing, etc. Adverse events will also be reported. Discussion This trial will assess the efficacy and safety of Maekmoondong-tang in chronic dry cough. Trial registration Korean Clinical Trial Registry (http://cris.nih.go.kr; registration number: KCT0001646). Date of registration: October 5 2015
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Gibson P, Wang G, McGarvey L, Vertigan AE, Altman KW, Birring SS. Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest 2016; 149:27-44. [PMID: 26426314 DOI: 10.1378/chest.15-1496] [Citation(s) in RCA: 224] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/09/2015] [Accepted: 08/12/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Unexplained chronic cough (UCC) causes significant impairments in quality of life. Effective assessment and treatment approaches are needed for UCC. METHODS This systematic review of randomized controlled trials (RCTs) asked: What is the efficacy of treatment compared with usual care for cough severity, cough frequency, and cough-related quality of life in patients with UCC? Studies of adults and adolescents aged > 12 years with a chronic cough of > 8 weeks' duration that was unexplained after systematic investigation and treatment were included and assessed for relevance and quality. Based on the systematic review, guideline suggestions were developed and voted on by using the American College of Chest Physicians organization methodology. RESULTS Eleven RCTs and five systematic reviews were included. The 11 RCTs reported data on 570 participants with chronic cough who received a variety of interventions. Study quality was high in 10 RCTs. The studies used an assortment of descriptors and assessments to identify UCC. Although gabapentin and morphine exhibited positive effects on cough-related quality of life, only gabapentin was supported as a treatment recommendation. Studies of inhaled corticosteroids (ICS) were affected by intervention fidelity bias; when this factor was addressed, ICS were found to be ineffective for UCC. Esomeprazole was ineffective for UCC without features of gastroesophageal acid reflux. Studies addressing nonacid gastroesophageal reflux disease were not identified. A multimodality speech pathology intervention improved cough severity. CONCLUSIONS The evidence supporting the diagnosis and management of UCC is limited. UCC requires further study to establish agreed terminology and the optimal methods of investigation using established criteria for intervention fidelity. Speech pathology-based cough suppression is suggested as a treatment option for UCC. This guideline presents suggestions for diagnosis and treatment based on the best available evidence and identifies gaps in our knowledge as well as areas for future research.
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Affiliation(s)
- Peter Gibson
- Hunter Medical Research Institute, New South Wales, Australia.
| | - Gang Wang
- Sichuan University, West China Hospital, Chengdu, China
| | | | | | | | - Surinder S Birring
- Division of Asthma, Allergy and Lung Biology, King's College London, London, England
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Abstract
Chronic cough is a frustrating and common problem, resulting in significant psychological and physical sequelae as well as enormous financial costs in terms of health care expense and time lost from work. Decreased QoL and depression are common. However, using a systematic approach, including assessing whether the patient uses ACE-I and cigarettes, excluding the presence of red flags and risk factors for life-threatening diseases, and obtaining and normal chest radiograph, more than 90% of cases of chronic cough are diagnosed as being caused by UACS, asthma, or GERD. It is recommended to address these conditions sequentially, starting with UACS. Nonasthmatic eosinophilic bronchitis and pertussis infections are unrecognized by primary care providers and should be considered after UACS, asthma, and GERD have been addressed. Finally, cough hypersensitivity syndrome is a new area of research and has been hypothesized to be the underlying factor in many cases of chronic cough, regardless of the inciting factor. More clinical research is needed to further elucidate the cough reflex pathway and the factors involved in modulating its sensitivity, which may eventually lead to new antitussive therapeutics.
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Affiliation(s)
- Genji Terasaki
- Division of General Internal Medicine, Harborview Medical Center, University of Washington, Box 359780, 325 Ninth Avenue, Seattle, WA 98104, USA.
| | - Douglas S Paauw
- Division of General Internal Medicine, University of Washington, Box 356420, BB527 Health Sciences Building, Seattle, WA 98195, USA
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Llor C, Moragas A, Bayona C, Morros R, Pera H, Plana-Ripoll O, Cots JM, Miravitlles M. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ 2013; 347:f5762. [PMID: 24097128 PMCID: PMC3790568 DOI: 10.1136/bmj.f5762] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the efficacy of oral anti-inflammatory or antibiotic treatment compared with placebo in the resolution of cough in patients with uncomplicated acute bronchitis and discoloured sputum. DESIGN Multicentre, parallel, single blinded placebo controlled, randomised clinical trial. SETTING Nine primary care centres in Spain. PARTICIPANTS Adults aged 18 to 70 presenting symptoms associated with respiratory tract infection of less than one week's duration, with cough as the predominant symptom, the presence of discoloured sputum, and at least one other symptom of lower respiratory tract infection (dyspnoea, wheezing, chest discomfort, or chest pain). INTERVENTIONS Patients were randomised to receive either ibuprofen 600 mg three times daily, amoxicillin-clavulanic acid 500 mg/125 mg three times daily, or placebo three times daily for 10 days. The duration of symptoms was measured with a diary card. MAIN OUTCOME MEASURE Number of days with frequent cough after the randomisation visit. RESULTS 416 participants were randomised (136 to ibuprofen, 137 to antibiotic, and 143 to placebo) and 390 returned their symptom diaries fully completed. The median number of days with frequent cough was slightly lower among patients assigned to ibuprofen (9 days, 95% confidence interval 8 to 10 days) compared with those receiving amoxicillin-clavulanic acid (11 days, 10 to 12 days) or placebo (11 days, 8 to 14 days), albeit without statistically significant differences. Neither amoxicillin-clavulanic acid nor ibuprofen increased the probability of cough resolution (hazard ratio 1.03, 95% confidence interval 0.78 to 1.35 and 1.23, 0.93 to 1.61, respectively) compared with placebo. Adverse events were observed in 27 patients, and were more common in the antibiotic arm (12%) than ibuprofen or placebo arms (5% and 3%, respectively; P<0.01). CONCLUSION No significant differences were observed in the number of days with cough between patients with uncomplicated acute bronchitis and discoloured sputum treated with ibuprofen, amoxicillin-clavulanic acid, or placebo. TRIAL REGISTRATION Current Controlled Trials ISRCTN07852892.
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Affiliation(s)
- Carl Llor
- Department of General Pathology. University Rovira i Virgili, Primary Care Centre Jaume I, c Felip Pedrell, 45-47 43005 Tarragona, Spain
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