Changes in the Burden of Comorbidities in Patients with COPD and Asthma-COPD Overlap According to the GOLD 2017 Recommendations

Burden of Disease in Patients with Mild or Mild-to-Moderate Chronic Obstructive Pulmonary Disease (Global Initiative for Chronic Obstructive Lung Disease Group A or B): A Systematic Literature Review

Background

Patients with mild or mild-to-moderate chronic obstructive pulmonary disease (COPD), defined as Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A/B, are regarded as having a lower risk of experiencing multiple or severe exacerbations compared with patients classified as GOLD group C/D. Current guidelines suggest that patients in GOLD A/B should commence treatment with a bronchodilator; however, some patients within this population who have a higher disease burden may benefit from earlier introduction of dual bronchodilator or inhaled corticosteroid-containing therapies. This study aimed to provide research-based insights into the burden of disease experienced by patients classified as GOLD A/B, and to identify characteristics associated with poorer outcomes.

Methods

A systematic literature review (SLR) was conducted to identify evidence (burden of disease and prevalence data) relating to the population of interest (patients with COPD classified as GOLD A/B).

Results

A total of 79 full-text publications and four conference abstracts were included. In general, the rates of moderate and severe exacerbations were higher among patients in GOLD group B than among those in group A. Among patients classified as GOLD A/B, the risk of exacerbation was higher in those with more symptoms (modified Medical Research Council or COPD Assessment Test scales) and more severe airflow limitation (forced expiratory volume in 1 second % predicted).

Conclusion

Data from this SLR provide clear evidence of a heavier burden of disease for patients in GOLD B, compared with those in GOLD A, and highlight factors associated with worse outcomes for patients in GOLD A/B.

The Role of Gut Bacteriome in Asthma, Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnoea

The human body contains a very complex and dynamic ecosystem of bacteria. The bacteriome interacts with the host bi-directionally, and changes in either factor impact the entire system. It has long been known that chronic airway diseases are associated with disturbances in the lung bacteriome. However, less is known about the role of gut bacteriome in the most common respiratory diseases. Here, we aim to summarise the evidence concerning the role of the intestinal bacteriome in the pathogenesis and disease course of bronchial asthma, chronic obstructive pulmonary disease, and obstructive sleep apnea. Furthermore, we discuss the consequences of an altered gut bacteriome on the most common comorbidities of these lung diseases. Lastly, we also reflect on the therapeutic potential of influencing the gut microbiome to improve disease outcomes.

Association of chronic inflammation with cardiovascular risk in chronic obstructive pulmonary disease—A cross‐sectional study

Background and Aims

COPD is progressive lung disease with known higher cardiovascular (CV) risk, mainly attributed to smoking of cigarettes as the main etiological factor of disease. The aim of this study was to compare CV risk in patients with COPD to control groups of smokers and non‐COPD and to investigate the relation of lung function variables, COPD severity, and smoking with Systemic Coronary Risk Estimation (SCORE) risk calculation, arterial stiffness (AS) values, and biological systemic inflammatory markers.

Methods

A total of 208 subjects were included in this study: 61 subjects diagnosed with COPD, 83 smokers without COPD, and 64 nonsmokers without COPD. Medical history and clinical data were recorded, including assessment of pulmonary function and AS, calculation of ankle‐brachial index, blood analysis, and CV risk assessment by SCORE risk calculation.

Results

Subjects with COPD had significantly higher values of SCORE calculation of risk, central aortic pressure, AS, and markers of systemic inflammation compared to control groups of smokers and nonsmokers without COPD (p < 0.001). Furthermore, statistically significant increase in hs‐CRP concentration was found between the COPD group and the control group of non‐COPD smokers (p < 0.001), and a statistically significantly higher SCORE calculation was found in the COPD group compared to control groups of smokers and nonsmokers without COPD (p < 0.001).

Conclusion

The results of the research support further identification and research of biological markers and simple specific tests such as arteriography that will enable progress in personalized treatment of patients with COPD and better primary and secondary prevention of comorbidities with the aim of improved treatment outcome.

What Are the Most Effective Factors in Determining Future Exacerbations, Morbidity Weight, and Mortality in Patients with COPD Attack?

Background and Objectives: This study aimed to investigate the important factors that affect COPD prognosis. Materials and Methods: We included 160 hospitalized patients with COPD exacerbation in the study. The hemoglobin (HB), hematocrit (HCT), leukocytes, red cell distribution width (RDW), mean platelet volume, platelet distribution width, plateletcrits, platelets, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, eosinophils, uric acid, albumin, C-reactive protein (CRP), procalcitonin, arterial blood gases (PO2 and PCO2), pulmonary function test (FEV1 and FVC), echocardiography (ejection fraction-EF), Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Modified Medical Research Council (mMRC) and Borg scales, Charlson comorbidity index, body mass index (BMI), and the length of hospital stay were examined on the first day of hospitalization. Admission to the hospital with a new attack, hospitalization in the intensive care unit (ICU), and mortality during the six months after discharge were evaluated. Results: High CRP and procalcitonin levels were observed in the group with a long hospital stay. In the mortality group, the HB, HCT, BMI, and PO2 values were significantly lower than in the group without mortality, while the age and GOLD stage were higher. The age, Borg and mMRC scores, number of exacerbations experienced in the previous year, RDW, eosinophil count, and PCO2 were significantly higher in the ICU group than that without an ICU stay. The HCT and EF values were lower in the ICU group than that without an ICU stay. The FEV1 and FVC values were significantly lower in the follow-up attack group than those without a follow-up attack. The duration of COPD and the number of attacks that were experienced in the previous year were high. Conclusion: Scoring combining selected biomarkers and other factors is a strong determinant of the prognosis.

Lower Prevalence of Osteoporosis in Patients with COPD Taking Anti-Inflammatory Compounds for the Treatment of Diabetes: Results from COSYCONET

Background

Patients with chronic obstructive pulmonary disease (COPD) often have osteoporosis and diabetes as comorbid conditions. Anti-diabetic medication, including metformin, has protective effects on osteoporosis in experimental studies. We therefore studied whether patients with COPD receiving anti-diabetic medication had a lower osteoporosis prevalence in a large COPD cohort, COSYCONET.

Methods

Assessment of osteoporosis was based on patients’ reports of physician-based diagnoses and the presence of disease-specific medication. The predictive value of physical characteristics, lung function, comorbidities, cardiovascular medication, and the use of anti-inflammatory diabetes medication, including metformin, sulfonylureas, glinides or DPP4I, was evaluated using logistic regression analysis. ClinicalTrials.gov: NCT01245933.

Results

In total, 2222 patients were eligible for analysis (863 [39%] female, mean age 65 y), 515 of whom had higher symptoms and exacerbations (Global Initiative for Chronic Obstructive Lung Disease group D). Osteoporosis was present in 15.8% of the overall cohort, and in 24.1% of GOLD D patients. Regression analyses identified the following as associated with osteoporosis (p < 0.05): female sex, higher age, lower body-mass index, asthma, higher air trapping, oral steroids, and cardiovascular medication. Although oral anti-diabetic medication was overall not associated with a lower prevalence of osteoporosis (p = 0.131), anti-inflammatory anti-diabetic medication (p = 0.009) and metformin-containing therapy (p = 0.039) were. This was driven by GOLD D patients.

Conclusion

In a large COPD cohort, anti-inflammatory diabetes therapy, including metformin, was associated with a lower prevalence of osteoporosis, especially in patients with higher symptoms and exacerbations. These findings suggest a protective effect of common anti-diabetic medication on osteoporosis, possibly as a result of attenuated systemic inflammation.

Narrative review of current COPD status in Japan

Chronic obstructive pulmonary disease (COPD) causes morbidity and mortality worldwide. Due to the improvement in environmental sanitation and medical care, the general life span has increased in the past decades in Japan. However, many older patients with COPD develop a wide range of comorbidities, and the impairments in the activities of daily living result in frailty and increase social and economic burdens. Population-based studies have shown that the prevalence of COPD is approximately 10% among subjects aged ≥40 years, but more than 80% of COPD patients are underdiagnosed. The Ministry of Health, Labour, and Welfare in Japan proposed the National Health Promotion in the 21st century, termed Health Japan 21 (the second term), in 2013 to prevent the onset and progression of noncommunicable diseases (NCDs), including COPD. The government, medical society, and community have been attempting to increase the recognition of COPD and promote smoking cessation. Additionally, Japanese cohorts have revealed distinct clinical features in Japanese patients with COPD, including lower rates of patient-reported exacerbations, less frequent coexisting cardiovascular disease and metabolic syndrome, and lower use of inhaled corticosteroids in Japan compared to the Western countries. Moreover, the poor adherence to inhaled medications is found in approximately 20% of subjects, and rehabilitation is performed in 26% of hospitalized patients with COPD. Therefore, more efforts should be made to improve adherence and access to pulmonary rehabilitation. Overall, Japanese COPD patients share common clinical and social features with COPD patients in other countries. Further international corroboration may help establish better comprehensive management of the disease.

Poor Cognitive Function Is Associated with Obstructive Lung Diseases in Taiwanese Adults

Previous studies have reported an association between the impairment of cognitive performance and lung diseases. However, whether obstructive or restrictive lung diseases have an impact on cognitive function is still inconclusive. We aimed to investigate the association between cognitive function and obstructive or restrictive lung diseases in Taiwanese adults using the Mini-Mental State Examination (MMSE). In this study, we used data from the Taiwan Biobank. Cognitive function was evaluated using the MMSE. Spirometry measurements of forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were obtained to assess lung function. Participants were classified into three groups according to lung function, namely, normal, restrictive, and obstructive lung function. In total, 683 patients enrolled, of whom 357 participants had normal lung function (52.3%), 95 had restrictive lung function (13.9%), and 231 had obstructive lung function (33.8%). Compared to the normal lung function group, the obstructive lung function group was associated with a higher percentage of cognitive impairment (MMSE < 24). In multivariable analysis, a low MMSE score was significantly associated with low FVC, low FEV1, and low FEV1/FVC. Furthermore, a low MMSE score was significantly associated with low FEV1 in the participants with FEV1/FVC < 70%, whereas MMSE was not significantly associated with FVC in the participants with FEV1/FVC ≥ 70%. Our results showed that a low MMSE score was associated with low FEV1, low FVC and low FEV1/FVC. Furthermore, a low MMSE score was associated with obstructive lung diseases but not with restrictive lung diseases.

The Role of Electronic Noses in Phenotyping Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a common progressive disorder of the respiratory system which is currently the third leading cause of death worldwide. Exhaled breath analysis is a non-invasive method to study lung diseases, and electronic noses have been extensively used in breath research. Studies with electronic noses have proved that the pattern of exhaled volatile organic compounds is different in COPD. More recent investigations have reported that electronic noses could potentially distinguish different endotypes (i.e., neutrophilic vs. eosinophilic) and are able to detect microorganisms in the airways responsible for exacerbations. This article will review the published literature on electronic noses and COPD and help in identifying methodological, physiological, and disease-related factors which could affect the results.

2011 GOLD Stages of COPD: Transitions, Predictor Factors and Comparison with 2017 GOLD Stages

Background

Despite wide use of the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) 2011, little is known about between-stage transitions and what factors predict worsening transitions in patients with chronic obstructive pulmonary disease (COPD).

Objective

To investigate the transition frequency between GOLD 2011 stages among patients with stable COPD over a 2-year follow-up, to identify potential non-pulmonary predictor factors for worsening transitions, and to compare transition frequencies between GOLD 2011 stages and the new GOLD 2017 stages.

Patients and Methods

We prospectively included 137 patients with stable COPD (mean age, 66.9 ± 8.3 years). GOLD 2011 and GOLD 2017 stages were measured at baseline, 1-year follow-up, and 2-year follow-up. To evaluate non-pulmonary variables as potential predictors of worsening transitions, we used regression models adjusted for sociodemographic, clinical, and pulmonary variables using generalized estimating equations.

Results

The study period included 246 opportunities for transition, and 39 worsening transitions occurred within GOLD 2011 stages. Predictors of worsening transitions included BODE index (OR, 1.20; 95% CI, 1.00–1.44), quadriceps strength (OR, 0.87; 95% CI, 0.76–0.99), and limited mobility activities (OR, 1.02; 95% CI, 1.00–1.05). The frequency of worsening transitions for stages B and C differed between GOLD 2011 and GOLD 2017. Stages A and D were the most stable in both classifications.

Conclusion

Non-pulmonary factors predicted worsening transitions among the GOLD 2011 stages of COPD severity. The choice of GOLD 2011 versus GOLD 2017 may influence transition identification, especially for stages B and C.

Impact of Clinical Factors on Generic and Disease-Specific Quality of Life in COPD and Asthma-COPD Overlap with Exacerbations

Purpose

The health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD) is worsened by frequent exacerbations, and it can be affected by the concomitant presence of bronchial asthma (asthma-COPD overlap (ACO)). The impacts of clinical factors associated with HRQL have not been compared in patients with COPD and ACO experiencing exacerbations. Patients and Methods. Patients with COPD (N =705) and ACO (N =148) belonging to C and D groups according to GOLD 2017 were recruited in stable condition. Demographic and clinical data were collected, spirometry was performed, and patients rated the intensity of respiratory symptoms during the previous week. The COPD Assessment Test (CAT) and the EQ-5D 3 level version (dimensions and visual analogue scale (VAS)) were used to assess disease-specific and generic HRQL, respectively. Fisher's exact test, χ² test, ANOVA, and Pearson correlation were used for analysis (mean ± SD). Multiple linear regression was applied to identify variables related to CAT and EQ-5D VAS scores.

Results

The CAT and EQ-5D VAS scores showed similarly low HRQL in COPD and ACO (20.7 ± 6.7 vs. 21.1 ± 6.3 (p = 0.52) and 56.2 ± 17.8 vs. 53.7 ± 18.2 (p = 0.11)). There was a weak correlation between CAT and EQ-5D VAS scores (COPD: r = −0.345, p < 0.001; ACO: r = −0.245, p = 0.003). More patients with COPD had problems related to anxiety/depression in EQ-5D (63.7% vs. 55.4%, p = 0.06). Pack-years exerted a negative effect on HRQL measures both in ACO and COPD. Low HRQL in COPD was associated with female gender, dyspnea, cough, gastroesophageal reflux disease, and arrhythmia, while in ACO, it was related to arrhythmia, hypertension, and cough, but less to dyspnea.

Conclusions

Patients with COPD and ACO experiencing exacerbations have low quality of life, which is influenced by smoking history, symptoms, and comorbidities. These findings have important implications for the development of therapeutic strategies to improve the health status of patients with these conditions.

Associations between Physical Activity and Comorbidities in People with COPD Residing in Spain: A Cross-Sectional Analysis

There is a high prevalence of comorbidities among patients with chronic obstructive pulmonary disease (COPD). Comorbidities are likely common in patients with any COPD degree and are associated with increased mortality. The aim of this study was to determine the prevalence of thirty-one different COPD comorbidities and to evaluate the association between physical activity (PA) levels in people with COPD residing in Spain. Cross-sectional data from the Spanish National Health Survey 2017 were analysed. A total of 601 adults (52.2% females) with COPD aged 15 to 69 participated in this study. PA (exposure) was measured with the International Physical Activity Questionnaire (IPAQ) short form and comorbidities (outcomes) were self-reported in response to the question "Have you ever been diagnosed with…?" Multivariable logistic regression, in three different models, was used to assess this association. Results showed a high prevalence of comorbidities (94%), these being chronic lumbar back pain (38.9%), chronic allergy (34.8%), arthrosis (34.1%), chronic cervical back pain (33.3%), asthma (32.9%) and hypertension (32.8%) the most prevalent. Low PA level was significantly associated with urinary incontinence (2.115[1.213-3.689]), chronic constipation (1.970[1.119-3.459]), cataracts (1.840[1.074-3.153]), chronic anxiety (1.508[1.002-2.269]) and chronic lumbar back pain (1.489[1.044-2.125]). Therefore, people with COPD should increase their PA levels in order to reduce their risk of comorbidities and increase their quality of life.

Classification and treatment of chronic obstructive pulmonary disease outpatients in China according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: comparison with GOLD 2014

Background

In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) proposed new classification criteria for patients with chronic obstructive pulmonary disease (COPD), which categorizes them into groups A-D based on risk of exacerbations and symptoms. The impact of the 2017 revisions on categorization and subsequent drug selection has been insufficiently studied in China.

Methods

This observational, multicenter, cross-sectional study recruited patients attending the outpatient clinics of 12 tertiary hospitals in China between April 2016 and July 2018. Patients were classified according to the GOLD 2014 and 2017 classification criteria and profiled based on categorization, demographics, clinical characteristics, and treatment regimens.

Results

In total, 1,278 COPD patients [mean age (±SD), 62.4±8.4 years; body mass index (BMI), 22.3±3.4 kg/m²] were included. According to the GOLD 2014 and 2017 classification criteria, the distribution in groups A-D was 58 (4.5%), 288 (22.5%), 28 (2.2%), 904 (70.7%) and 71 (5.6%), 573 (44.8%), 15 (1.2%), 619 (48.4%), respectively. Overall, 32% of patients in groups C-D were reclassified to groups A-B. Based on both GOLD 2014 and 2017, low BMI and education level were independent risk factors for high risk of exacerbation (i.e., being in groups C-D) (P<0.05). The patients who were reclassified from group D to B were younger and had fewer symptoms than those who remained in group D. The most frequently prescribed regimen was triple inhaled treatment (39.4%). Inhaled corticosteroids (ICS) were prescribed across all groups, and 205 (71.9%) of the 285 patients who were reclassified from group D to B were treated with ICS.

Conclusions

GOLD 2017 reclassified COPD patients to low-risk groups. The risk of exacerbation increased with decreased BMI or education levels. Overtreatment was observed in many patients, and physicians should reexamine treatment patterns for patients reclassified into low-risk groups.

Soluble Urokinase-Type Plasminogen Activator Receptor and Arterial Stiffness in Patients with COPD

Introduction

Soluble urokinase-type plasminogen activator receptor (suPAR) is upregulated by inflammation and plays a role in the pathogenesis of atherosclerosis. Chronic obstructive pulmonary disease (COPD) is associated with enhanced systemic inflammation and increased risk for atherosclerosis, however, studies analysing the circulating suPAR levels in COPD are contradictory. The aim of the study was to investigate plasma suPAR concentrations together with markers of arterial stiffness in COPD.

Materials and Methods

Twenty-four patients with COPD and 18 non-COPD, control subjects participated in the study. Plasma suPAR was measured, together with lung volumes, symptom burden, exacerbation history, markers of arterial stiffness and soluble inflammatory biomarkers, such as endothelin-1, high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6).

Results

Plasma suPAR levels were higher in COPD (2.84 ± 0.67 ng/ml vs. 2.41 ± 0.57 ng/ml, p = 0.03) and were related to lung function measured with FEV₁ (r = − 0.65, p < 0.01) and symptom burden determined with the modified Medical Research Council questionnaire (r = 0.55, p < 0.05). Plasma suPAR concentrations correlated with various measures of arterial stiffness in all subjects, but only with ejection duration in COPD (r = − 0.44, p = 0.03).

Conclusions

Plasma suPAR levels are elevated in COPD and relate to arterial stiffness. Our results suggest that suPAR may be a potential link between COPD and atherosclerosis.