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Jessamine V, Mehndiratta S, De Rubis G, Paudel KR, Shetty S, Suares D, Chellappan DK, Oliver BG, Hansbro PM, Dua K. The application of nanoparticles as advanced drug delivery systems in Attenuating COPD. Heliyon 2024; 10:e25393. [PMID: 38356590 PMCID: PMC10864912 DOI: 10.1016/j.heliyon.2024.e25393] [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: 07/22/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a dilapidating condition which is characterized by inflammation, an excess in free radical generation and airway obstruction. Currently, the drugs commercially available for the management of COPD pose several limitations such as systemic adverse effects, including bone density loss and an increased risk of developing pneumonia. Moreover, another limitation includes the need for regular and frequent dosing regimens; which can affect the adherence to the therapy. Furthermore, these current treatments provide symptomatic relief; however, they cannot stop the progression of COPD. Comparatively, nanoparticles (NPs) provide great therapeutic potential to treat COPD due to their high specificity, biocompatibility, and higher bioavailability. Furthermore, the NP-based drug delivery systems involve less frequent dosing requirements and in smaller doses which assist in minimizing side effects. In this review, the benefits and limitations of conventional therapies are explored, while providing an in-depth insight on advanced applications of NP-based systems in the treatment of COPD.
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Affiliation(s)
- Victoria Jessamine
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, NSW, 2007, Australia
| | - Samir Mehndiratta
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, NSW, 2007, Australia
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Gabriele De Rubis
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, NSW, 2007, Australia
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Keshav Raj Paudel
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia
- Centre for Inflammation, Centenary Institute and University of technology Sydney, Faculty of Science, School of Life Sciences, Sydney, NSW, 2007, Australia
| | - Saritha Shetty
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's, NMIMS Deemed to Be University, Mumbai, 400056, Maharashtra, India
| | - Divya Suares
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's, NMIMS Deemed to Be University, Mumbai, 400056, Maharashtra, India
| | - Dinesh Kumar Chellappan
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, 578000, Malaysia
| | - Brian G. Oliver
- School of Life Sciences, University of Technology Sydney, Ultimo, NSW, 2007, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Phillip M. Hansbro
- Centre for Inflammation, Centenary Institute and University of technology Sydney, Faculty of Science, School of Life Sciences, Sydney, NSW, 2007, Australia
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, NSW, 2007, Australia
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia
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Lu C, Mao X. Risk of adverse reactions associated with inhaled corticosteroids for chronic obstructive pulmonary disease: A meta-analysis. Medicine (Baltimore) 2024; 103:e36609. [PMID: 38241558 PMCID: PMC10798756 DOI: 10.1097/md.0000000000036609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/21/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND In the majority of current therapeutic regimens for chronic obstructive pulmonary disease (COPD), bronchodilators are coupled with inhaled corticosteroids (ICS) to lower the inflammatory response and improve symptoms. This study aims to evaluate the safety of ICS in the treatment of COPD. METHODS Randomized controlled trials related to ICS for COPD that were eligible up to 1 June 2023 were searched in PubMed, EMBASE, and Cochrane. We searched and screened eligible studies for the occurrence of total adverse events, cardiovascular events, upper respiratory tract infections (URTI), pneumonia, oral Candida infections, and musculoskeletal disorders, and finally analyzed them by Review Manager 5.4.1. RESULTS The results showed that ICS increased the incidence of adverse reactions in COPD patients (RR = 1.06, 95% CI: 1.03-1.10, P = .0004); ICS treatment did not increase the risk of cardiovascular events in COPD patients (RR = 0.95, 95% CI: 0.88-1.02, P = .14); ICS increased the incidence of URTI in COPD patients (RR = 1.29, 95% CI: 1.02-1.62, P = .03); ICS increased the incidence of pneumonia in patients with COPD (RR = 2.09, 95% CI: 1.63-2.69, P < .00001); ICS treatment significantly increased the incidence of oral Candida in patients with COPD (RR = 2.96, 95% CI: 1.99-4.41, P < .00001); ICS increased the incidence of musculoskeletal disorders in patients with COPD (RR = 2.87, 95% CI: 1.51-5.45, P = .001). CONCLUSION ICS does not increase the risk of cardiovascular events in patients with COPD, but it does increase the risk of URTI, pneumonia, oral Candida infections, and musculoskeletal disorders in patients with COPD.
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Affiliation(s)
- Chenghe Lu
- Department of Respiratory Medicine, Cangnan County Hospital of Traditional Chinese Medicine, Wenzhou City, Zhejiang Province, China
| | - Xinghua Mao
- Department of Acupuncture, Cangnan County Hospital of Traditional Chinese Medicine, Wenzhou City, Zhejiang Province, China
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Gong Y, Sui Z, Lv Y, Zheng Q, Li L. LABA/LAMA versus LABA/ICS fixed-dose combinations in the prevention of COPD exacerbations: a modeling analysis of literature aggregate data. Eur J Clin Pharmacol 2023; 79:1321-1332. [PMID: 37507595 DOI: 10.1007/s00228-023-03543-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVES This study aimed to quantitatively compare the efficacy and safety of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) and LABA/inhaled corticosteroid (ICS) fixed-dose combinations (FDCs) in preventing moderate or severe chronic obstructive pulmonary disease (COPD) exacerbations. METHODS A literature search was performed using public databases. The time course characteristics of the probability of a moderate or severe exacerbation in stable COPD patients treated with LABA/LAMA and LABA/ICS FDCs were described by the parametric survival function. A random-effects model in a single-arm meta-analysis was used to analyze the incidence of serious adverse events (SAEs) and pneumonia. RESULTS Twenty studies including 23,955 participants were included. The proportion of participants with a history of COPD exacerbation (%) in the previous year and the postbronchodilator forced expiratory volume in the first second (FEV1) (%predicted) were important factors affecting drug efficacy. After adjusting the above factors to median levels of 100% and 45.5%, respectively, the moderate or severe exacerbation rates at 52 weeks for olodaterol/tiotropium, formoterol/budesonide, indacaterol/glycopyrronium, formoterol/glycopyrronium, vilanterol/fluticasone, salmeterol/fluticasone, and vilanterol/umeclidinium were 38.3%, 41.0%, 42.6%, 47.0%, 47.5%, 47.9%, and 53.0%, respectively. In terms of safety, significant differences were observed among drugs containing different LABA/LAMA FDCs. CONCLUSIONS This study showed that not all LABA/LAMA FDCs were superior to LABA/ICS FDCs in safety and in preventing moderate or severe exacerbations in patients with stable COPD, providing important quantitative information for COPD-related guidelines.
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Affiliation(s)
- Yiwen Gong
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Zichao Sui
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Yinghua Lv
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Qingshan Zheng
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Lujin Li
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China.
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Peng S, Tan C, Du L, Niu Y, Liu X, Wang R. Effect of fracture risk in inhaled corticosteroids in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMC Pulm Med 2023; 23:304. [PMID: 37592316 PMCID: PMC10436625 DOI: 10.1186/s12890-023-02602-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The fracture risk of patients with chronic obstructive pulmonary disease (COPD) treated with inhaled corticosteroids is controversial. And some large-scale randomized controlled trials have not solved this problem. The purpose of our systematic review and meta-analysis including 44 RCTs is to reveal the effect of inhaled corticosteroids on the fracture risk of COPD patients. METHODS Two reviewers independently retrieved randomized controlled trials of inhaled corticosteroids or combinations of inhaled corticosteroids in the treatment of COPD from PubMed, Embase, Medline, Cochrane Library, and Web of Science. The primary outcome was a fracture event. This study was registered at PROSPERO (CRD42022366778). RESULTS Forty-four RCTs were performed in 87,594 patients. Inhaled therapy containing ICSs (RR, 1.19; 95%CI, 1.04-1.37; P = 0.010), especially ICS/LABA (RR, 1.30; 95%CI, 1.10-1.53; P = 0.002) and triple therapy (RR, 1.49; 95%CI, 1.03-2.17; P = 0.04) were significantly associated with the increased risk of fracture in COPD patients when compared with inhaled therapy without ICSs. Subgroup analyses showed that treatment duration ≥ 12 months (RR, 1.19; 95%CI, 1.04-1.38; P = 0.01), budesonide therapy (RR, 1.64; 95%CI., 1.07-2.51; P = 0.02), fluticasone furoate therapy (RR, 1.37; 95%CI, 1.05-1.78; P = 0.02), mean age of study participants ≥ 65 (RR, 1.27; 95%CI, 1.01-1.61; P = 0.04), and GOLD stage III(RR, 1.18; 95%CI, 1.00-1.38; P = 0.04) were significantly associated with an increased risk of fracture. In addition, budesonide ≥ 320 ug bid via MDI (RR, 1.75; 95%CI, 1.07-2.87; P = 0.03) was significantly associated with the increased risk of fracture. CONCLUSION Inhalation therapy with ICSs, especially ICS/LABA or triple therapy, increased the risk of fracture in patients with COPD compared with inhaled therapy without ICS. Treatment duration, mean age of participants, GOLD stage, drug dosage form, and drug dose participated in this association. Moreover, different inhalation devices of the same drug also had differences in risk of fracture.
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Affiliation(s)
- Shisheng Peng
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Cong Tan
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Lirong Du
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yanan Niu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xiansheng Liu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ruiying Wang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
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Practical Recommendations for a Selection of Inhaled Corticosteroids in COPD: A Composite ICO Chart. Biomolecules 2023; 13:biom13020213. [PMID: 36830583 PMCID: PMC9953425 DOI: 10.3390/biom13020213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/25/2023] Open
Abstract
The use of inhaled corticosteroids (ICS) for the maintenance of bronchodilator treatment in patients with chronic obstructive pulmonary disease (COPD) is controversial. While some patients achieve clinical benefits, such as fewer exacerbations and improved symptoms, others do not, and some experience undesired side effects, such as pneumonia. Thus, we reviewed the evidence related to predictors of ICS therapy treatment response in patients with COPD. The first priority clinical markers when considering the efficacy of ICS are type 2 inflammatory biomarkers, followed by a history of suspected asthma and recurrent exacerbations. It is also necessary to consider any potential infection risk associated with ICS, and several risk factors for pneumonia when using ICS have been clarified in recent years. In this article, based on the evidence supporting the selection of ICS for COPD, we propose an ICS composite that can be added to the COPD (ICO) chart for use in clinical practice. The chart divided the type 2 biomarkers into three ranges and provided recommendations (recommend, consider, and against) by combining the history of suspected asthma, history of exacerbations, and risk of infection.
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Chen H, Deng ZX, Sun J, Huang Q, Huang L, He YH, Ma C, Wang K. Association of Inhaled Corticosteroids With All-Cause Mortality Risk in Patients With COPD: A Meta-analysis of 60 Randomized Controlled Trials. Chest 2023; 163:100-114. [PMID: 35921883 DOI: 10.1016/j.chest.2022.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/04/2022] [Accepted: 07/17/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICSs) have been used widely in the maintenance therapy of COPD. However, whether inhaled therapy containing ICSs can reduce the all-cause mortality risk and the possible benefited patient subgroups is unclear. RESEARCH QUESTION Does inhaled therapy containing ICSs reduce the all-cause mortality risk in patients with COPD compared with other inhaled therapies not containing ICSs? STUDY DESIGN AND METHODS We searched PubMed, Cochrane Library, Embase, and ClinicalTrials.gov for relevant randomized clinical trials (RCTs). Pooled results were calculated using Peto ORs with corresponding 95% CIs. RESULTS Sixty RCTs enrolling 103,034 patients were analyzed. Inhaled therapy containing ICSs (Peto OR, 0.90; 95% CI, 0.84-0.97), especially triple therapy (Peto OR, 0.73; 95% CI, 0.59-0.91), was associated with a reduction in the all-cause mortality risk among patients with COPD when compared with inhaled therapy without ICSs. Subgroup analyses revealed that treatment duration of > 6 months (Peto OR, 0.90; 95% CI, 0.83-0.97), medium-dose ICSs (Peto OR, 0.71; 95% CI, 0.56-0.91), low-dose ICSs (Peto OR, 0.88; 95% CI, 0.79-0.97), and budesonide (Peto OR, 0.75; 95% CI, 0.59-0.94) were involved in this association. The predictors of this association included eosinophil counts of ≥ 200/μL or percentage of ≥ 2%, documented history of ≥ 2 moderate and severe exacerbations in the previous year, Global Initiative for Chronic Obstructive Lung Disease stages III or IV, age younger than 65 years, and BMI of ≥ 25 kg/m2, among which eosinophil counts of ≥ 200/μL (Peto OR, 0.58; 95% CI, 0.36-0.95) were the strongest predictor. INTERPRETATION Inhaled therapy containing ICSs, especially triple therapy, of longer than 6 months was associated with a reduction in the all-cause mortality risk in patients with COPD. The predictors of this association included medication factors and patient characteristics, among which eosinophil counts of ≥ 200/μL were the strongest predictor. TRIAL REGISTRY PROSPERO; No.: CRD42022304725; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Hong Chen
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Zheng-Xu Deng
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Jian Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Qiang Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Lan Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Yong-Hong He
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Chunlan Ma
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
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Archontakis Barakakis P, Tran T, You JY, Hernandez Romero GJ, Gidwani V, Martinez FJ, Fortis S. High versus Medium Dose of Inhaled Corticosteroid in Chronic Obstructive Lung Disease: A Systematic Review and Meta-Analysis. Int J Chron Obstruct Pulmon Dis 2023; 18:469-482. [PMID: 37056683 PMCID: PMC10086393 DOI: 10.2147/copd.s401736] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
Background Inhaled corticosteroids (ICSs) combined with bronchodilators have been identified to improve outcomes in COPD but also to be associated with certain adverse effects. Objective We performed a systematic review and meta-analysis to compile and summarize data on the efficacy and safety of dosing levels (high versus medium/low) of ICS alongside ancillary bronchodilators following PRISMA guidelines. Data Sources Medline and Embase were systematically searched until December 2021. Randomized, clinical trials (RCTs) that met predefined inclusion criteria were included. Data Extraction Risk ratios (RRs) with 95% confidence intervals (CI) were extracted. Any acute exacerbation of COPD (AECOPD) risk was chosen as the primary efficacy outcome, mortality rate as the primary safety outcome, moderate/severe AECOPD risk as the secondary efficacy outcome and pneumonia risk as the secondary safety outcome. Subgroup analyses of individual ICS agents, of patients with baseline moderate/severe/very severe COPD and of patients with recent COPD exacerbation history were also performed. A random-effects model was used. Results We included 13 RCTs in our study. No data on low doses were included in the analysis. High dose ICS was not associated with a statistically significant difference in any AECOPD risk (RR: 0.98, 95% CI: 0.91-1.05, I2: 41.3%), mortality rate (RR: 0.99, 95% CI: 0.75-1.32, I2: 0.0%), moderate/severe AECOPD risk (RR: 1.01, 95% CI: 0.96-1.06, I2: 0.0%) or pneumonia risk (RR: 1.07, 95% CI: 0.86 -1.33, I2: 9.3%) compared to medium dose ICS. The same trend was identified with the several subgroup analyses. Conclusion Our study collected RCTs investigating the optimal dosing level of ICS prescribed alongside ancillary bronchodilators to patients with COPD. We identified that the high ICS dose neither reduces AECOPD risk and mortality rates nor increases pneumonia risk relative to the medium dose.
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Affiliation(s)
- Paraschos Archontakis Barakakis
- Northeast Internal Medicine Associates, LaGrange, IN, USA
- Correspondence: Paraschos Archontakis Barakakis, Northeast Internal Medicine Associates, 4344 Love Grass Lane, Fort Wayne, LaGrange, IN, 46845, USA, Tel +1 929-422-4589, Email
| | - Thuonghien Tran
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Jee Young You
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Vipul Gidwani
- Northeast Internal Medicine Associates, LaGrange, IN, USA
| | - Fernando J Martinez
- Departments of Medicine and Genetic Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Spyridon Fortis
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Veterans Rural Health Resource Center, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
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Brown MA, Jabeen M, Bharj G, Hinks TSC. Non-typeable Haemophilus influenzae airways infection: the next treatable trait in asthma? Eur Respir Rev 2022; 31:220008. [PMID: 36130784 PMCID: PMC9724834 DOI: 10.1183/16000617.0008-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 07/04/2022] [Indexed: 11/05/2022] Open
Abstract
Asthma is a complex, heterogeneous condition that affects over 350 million people globally. It is characterised by bronchial hyperreactivity and airways inflammation. A subset display marked airway neutrophilia, associated with worse lung function, higher morbidity and poor response to treatment. In these individuals, recent metagenomic studies have identified persistent bacterial infection, particularly with non-encapsulated strains of the Gram-negative bacterium Haemophilus influenzae. Here we review knowledge of non-typeable H. influenzae (NTHi) in the microbiology of asthma, the immune consequences of mucosal NTHi infection, various immune evasion mechanisms, and the clinical implications of NTHi infection for phenotyping and targeted therapies in neutrophilic asthma. Airway neutrophilia is associated with production of neutrophil chemokines and proinflammatory cytokines in the airways, including interleukin (IL)-1β, IL-6, IL-8, IL-12, IL-17A and tumour necrosis factor. NTHi adheres to and invades the lower respiratory tract epithelium, inducing the NLR family pyrin domain containing 3 (NLRP3) and absent in melanoma 2 (AIM2) inflammasomes. NTHi reduces expression of tight-junction proteins, impairing epithelial integrity, and can persist intracellularly. NTHi interacts with rhinoviruses synergistically via upregulation of intracellular cell adhesion molecule 1 and promotion of a neutrophilic environment, to which NTHi is adapted. We highlight the clinical relevance of this emerging pathogen and its relevance for the efficacy of long-term macrolide therapy in airways diseases, we identify important unanswered questions and we propose future directions for research.
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Affiliation(s)
- Mary Ashley Brown
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Maisha Jabeen
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Gurpreet Bharj
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
- Mammalian Genetics Unit, MRC Harwell Institute, Oxford, UK
| | - Timothy S C Hinks
- Respiratory Medicine Unit and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Experimental Medicine Division, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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Ding Y, Sun L, Wang Y, Zhang J, Chen Y. Efficacy of ICS versus Non-ICS Combination Therapy in COPD: A Meta-Analysis of Randomised Controlled Trials. Int J Chron Obstruct Pulmon Dis 2022; 17:1051-1067. [PMID: 35547781 PMCID: PMC9084385 DOI: 10.2147/copd.s347588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/24/2022] [Indexed: 12/15/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Yanling Ding
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Lina Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Ying Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
- Correspondence: Jing Zhang; Yahong Chen, Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China, Tel +86 13-8104-57631, Email ;
| | - Yahong Chen
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
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10
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Wise RA, Bafadhel M, Crim C, Criner GJ, Day NC, Halpin DMG, Han MK, Lange P, Lipson DA, Martinez FJ, Maselli DJ, Midwinter D, Singh D, Zysman M, Dransfield MT, Russell REK. Discordant diagnostic criteria for pneumonia in COPD trials: a review. Eur Respir Rev 2021; 30:30/162/210124. [PMID: 34789465 PMCID: PMC9488621 DOI: 10.1183/16000617.0124-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/28/2021] [Indexed: 01/21/2023] Open
Abstract
Inhaled corticosteroids (ICS) have a class effect of increasing pneumonia risk in patients with COPD. However, pneumonia incidence varies widely across clinical trials of ICS use in COPD. This review clarifies methodological differences in defining and recording pneumonia events in these trials and discusses factors that could contribute to the varying pneumonia incidence. Literature searches and screening yielded 40 relevant references for inclusion. Methods used to capture pneumonia events in these studies included investigator-reported pneumonia adverse events, standardised list of signs or symptoms, radiographic confirmation of suspected cases and/or confirmation by an independent clinical end-point committee. In general, more stringent pneumonia diagnosis criteria led to lower reported pneumonia incidence rates. In addition, studies varied in design and population characteristics, including exacerbation history and lung function, factors that probably contribute to the varying pneumonia incidence. As such, cross-trial comparisons are problematic. A minimal set of standardised criteria for diagnosis and reporting of pneumonia should be used in COPD studies, as well as reporting of patients’ pneumonia history at baseline, to allow comparison of pneumonia rates between trials. Currently, within-trial comparison of ICS-containing versus non-ICS-containing treatments is the appropriate method to assess the influence of ICS on pneumonia incidence. Trials of ICS in COPD use varying methods of reporting pneumonia incidence, which influence the interpretation of results. A minimal set of standardised criteria for pneumonia diagnosis would allow comparison of pneumonia incidence between trials.https://bit.ly/3nbkdoL
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Affiliation(s)
- Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mona Bafadhel
- Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Courtney Crim
- Clinical Sciences - Respiratory, GSK, Research Triangle Park, NC, USA.,Affiliation at the time of writing
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - MeiLan K Han
- University of Michigan, Pulmonary & Critical Care, Ann Arbor, MI, USA
| | - Peter Lange
- Section of Epidemiology, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical Dept, Herlev and Gentofte Hospital, Herlev, Denmark
| | - David A Lipson
- Clinical Sciences, GSK, Collegeville, PA, USA.,Pulmonary, Allergy and Critical Care Division, Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando J Martinez
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Diego J Maselli
- Dept of Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
| | | | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Foundation Hospital Trust, Manchester, UK
| | - Maeva Zysman
- Service des Maladies Respiratoires, CHU Bordeaux, Pessac, France.,Univ-Bordeaux, Centre de Recherche cardio-thoracique de Bordeaux, U1045, CIC 1401, Pessac, France
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
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11
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Yebyo HG, Braun J, Menges D, Ter Riet G, Sadatsafavi M, Puhan MA. Personalising add-on treatment with inhaled corticosteroids in patients with chronic obstructive pulmonary disease: a benefit-harm modelling study. LANCET DIGITAL HEALTH 2021; 3:e644-e653. [PMID: 34452874 DOI: 10.1016/s2589-7500(21)00130-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since the benefit-harm balance of adding inhaled corticosteroids to long-acting β2-agonists (LABA) and long-acting muscarinic antagonists (LAMA) for patients with chronic obstructive pulmonary disease is unclear, we evaluated this addition for a range of patient profiles. METHODS Analyses considered the effects of low-to-moderate doses of inhaled corticosteroids, LABA, and LAMA compared with LABA and LAMA alone, outcome incidences, and preference weights assigned to averted moderate-to-severe exacerbations (benefit) and severe pneumonia, candidiasis, and dysphonia (harm). Using exponential models, we estimated the preference weight-adjusted 2-year net clinical benefit (ie, benefits outweighing harms) indices. Exacerbation risk thresholds for triggering inhaled corticosteroids, LABA, and LAMA were established when the probability of a 2-year net clinical benefit reached 60%. We estimated the proportion of patients benefiting from added inhaled corticosteroids using an externally validated prediction model for acute exacerbations in primary care. FINDINGS Adding low-to-moderate dose inhaled corticosteroids to LABA and LAMA provided a net clinical benefit in patients with a 2-year baseline exacerbation risk of 54-83%. Low-dose inhaled corticosteroids showed a net clinical benefit if the baseline risk was 40-91%, but not at higher doses. The benefit was modified by blood eosinophil count (BEC) and age. Although no net benefit was associated with a BEC of less than 150 cells per μL, patients with a BEC of 150 cells per μL or more had a net benefit from low-dose inhaled corticosteroids with a 2-year exacerbation risk of 32-95% in those aged 40-79 years and 41-93% in those older than 80 years. A moderate dose of inhaled corticosteroids showed a net benefit in patients younger than 80 years with a BEC of 150 cells per μL or more at 52-86% 2-year exacerbation risk. Depending on the subgroups, the proportion of patients with a net benefit from added inhaled corticosteroids ranged from 0 to 68%. INTERPRETATION The net clinical benefit of adding different inhaled corticosteroid doses to LABA and LAMA varies greatly with exacerbation risk, BEC, and age. Personalised treatment decisions based on these factors and predicted exacerbation risks might reduce overtreatment and undertreatment with inhaled corticosteroids. FUNDING None.
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Affiliation(s)
- Henock G Yebyo
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Julia Braun
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dominik Menges
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Gerben Ter Riet
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Urban Vitality Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Programme, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Milo A Puhan
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland.
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12
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Pu X, Liu L, Feng B, Zhang Z, Wang G. Association between ICS use and risk of hyperglycemia in COPD patients: systematic review and meta-analysis. Respir Res 2021; 22:201. [PMID: 34238280 PMCID: PMC8265114 DOI: 10.1186/s12931-021-01789-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The effect of inhaled corticosteroids (ICS) on risk of hyperglycemia in patients with chronic obstructive pulmonary disease (COPD) remains ambiguous. The aim of this study is to evaluate the association between ICS use and the incidence of hyperglycemia related adverse effects in COPD patients. METHODS Medline/PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched from inception to 25 May 2020. Randomized controlled trials (RCTs) of ICS versus control (non-ICS) treatment for COPD patients reporting on risk of hyperglycemia were included. The Mantel-Haenszel method with fixed-effects modeling was used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). RESULTS Seventeen RCTs with 43,430 subjects were included in the meta-analysis. Pooled results suggested that there was no statistically significant difference in the risk of hyperglycemia between the ICS group and the control group (RR 1.02, 95% CI 0.90-1.16, P = 0.76). In addition, no significant difference was noted in the effect on glucose level (RR 1.20, 95% CI 0.79-1.82, P = 0.40), risk of diabetes progression (RR 0.84, 95% CI 0.20-3.51, P = 0.81) and new onset diabetes mellitus (RR 1.0, 95% CI 0.88-1.15, P = 0.95) between the ICS group and the control group. These findings also were consistent across all subgroup analyses. CONCLUSIONS Use of ICS does not have an effect on the blood glucose and is not associated with the risk of new onset diabetes mellitus and diabetes progression in patients with COPD. Further RCTs exploring the association between ICS use and risk of hyperglycemia in COPD patients are still needed to verify our results of this analysis.
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Affiliation(s)
- Xiaofeng Pu
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, China
| | - Liang Liu
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, Luzhou, 646000, China
| | - Bimin Feng
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, Luzhou, 646000, China
| | - Zhengji Zhang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, China
| | - Guojun Wang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, China.
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13
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Liu T, Xiang ZJ, Hou XM, Chai JJ, Yang YL, Zhang XT. Blood eosinophil count-guided corticosteroid therapy and as a prognostic biomarker of exacerbations of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Ther Adv Chronic Dis 2021; 12:20406223211028768. [PMID: 34285789 PMCID: PMC8267047 DOI: 10.1177/20406223211028768] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is characterized by persistent respiratory symptoms and dyspnea, as well as an increase in the number of leukocytes in the airways, lungs, and pulmonary vessels. A 'One size fits all' approach to COPD patients with different clinical features may be considered outdated. The following are the two major objectives of this meta-analysis: the first is to determine if blood eosinophil counts (BEC) can serve as a prognostic biomarker of COPD outcomes, and the second is to determine which level of BEC is effective for inhaled corticosteroid (ICS) treatment. METHODS We searched articles published before 15 May 2021 in the following four electronic databases: Web of Science, Cochrane Library, EMBASE, and PubMed. RESULTS A total of 42 studies, comprising a sampling of 188,710 subjects, were summarized and compared in this meta-analysis. The rate ratio (RR) of exacerbations of COPD (ECOPD) between ICS and non-ICS treatment was statistically significant for the COPD patients with a baseline BEC ⩾ 2% or ⩾ 200 cells/μl, RR = 0.82 (0.73, 0.93) or 0.79 (0.70, 0.89) respectively, while the RR of ECOPD between ICS and non-ICS treatment was statistically insignificant for the COPD patients with baseline BEC < 2% or <200 cells/μl, RR = 0.97 (0.87, 1.08) or 0.97 (0.86, 1.08), suggested that ICS therapy was beneficial to the improvement of ECOPD in patients with a baseline BEC ⩾ 2% or BEC ⩾ 200 cells/μl. CONCLUSION Our research shows that a BEC ⩾ 200 cells/μl or ⩾2% is likely to become the cutoff value of ICS treatment for ECOPD. Moreover, we believe that the baseline BEC can be used as a biomarker for predicting ECOPD. The stability of BEC requires special attention.
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Affiliation(s)
- Tao Liu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Jian Xiang
- Beijing Zhiyun Data Technology Co. LTD, Beijing, China
| | - Xiao-Meng Hou
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Jing Chai
- Department of Emergency Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Li Yang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Tong Zhang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
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14
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Chen H, Sun J, Huang Q, Liu Y, Yuan M, Ma C, Yan H. Inhaled Corticosteroids and the Pneumonia Risk in Patients With Chronic Obstructive Pulmonary Disease: A Meta-analysis of Randomized Controlled Trials. Front Pharmacol 2021; 12:691621. [PMID: 34267661 PMCID: PMC8275837 DOI: 10.3389/fphar.2021.691621] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Whether all types of inhaled corticosteroids (ICSs) would increase the pneumonia risk in patients with chronic obstructive pulmonary disease (COPD) remains controversial. We aimed to assess the association between ICSs treatment and pneumonia risk in COPD patients, and the impact of medication details and baseline characteristics of patients on the association. Methods: Four databases (PubMed, Embase, Cochrane Library, and Clinical Trials.gov) were searched to identify eligible randomized controlled trials (RCTs) comparing ICSs treatment with non-ICSs treatment on the pneumonia risk in COPD patients. Pooled results were calculated using Peto odds ratios (Peto ORs) with corresponding 95% confidence intervals (CIs). Results: A total of 59 RCTs enrolling 103,477 patients were analyzed. All types of ICSs significantly increased the pneumonia risk (Peto OR, 1.43; 95% CI, 1.34–1.53). Subgroup analysis showed that there was a dose-response relationship between ICSs treatment and pneumonia risk (low-dose: Peto OR, 1.33; 95% CI, 1.22–1.45; medium-dose: Peto OR, 1.50; 95% CI, 1.28–1.76; and high-dose: Peto OR, 1.64; 95% CI, 1.45–1.85). Subgroup analyses based on treatment durations and baseline characteristics (severity, age, and body mass index) of patients were consistant with the above results. Subgroup analysis based on severity of pneumonia showed that fluticasone (Peto OR, 1.75; 95% CI, 1.44–2.14) increased the risk of serious pneumonia, while budesonide and beclomethasone did not. Conclusions: ICSs treatment significantly increased the risk of pneumonia in COPD patients. There was a dose-response relationship between ICSs treatment and pneumonia risk. The pneumonia risk was related with COPD severity.
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Affiliation(s)
- Hong Chen
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Jian Sun
- Department of Respiratory, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Qiang Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Yongqi Liu
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Mengxin Yuan
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Chunlan Ma
- Department of Respiratory, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Hao Yan
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
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15
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Miravitlles M, Auladell-Rispau A, Monteagudo M, Vázquez-Niebla JC, Mohammed J, Nuñez A, Urrútia G. Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD. Eur Respir Rev 2021; 30:30/160/210075. [PMID: 34168063 DOI: 10.1183/16000617.0075-2021] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/26/2021] [Indexed: 11/05/2022] Open
Abstract
Inhaled corticosteroids (ICSs) are indicated for the prevention of exacerbations in COPD; however, a significant proportion of patients at low risk of exacerbations are treated with ICSs. We conducted a systematic review including a diversity of types of study designs and safety outcomes with the objective of describing the risk of adverse effects associated with the long-term use of ICSs in patients with COPD.A total of 90 references corresponding to 83 studies were included, including 26 randomised clinical trials (RCTs), 33 cohort studies, and 24 nested case-control (NCC) studies. Analysis of 19 RCTs showed that exposure to ICSs for ≥1 year increased the risk of pneumonia by 41% (risk ratio 1.41, 95% CI 1.23-1.61). Additionally, cohort and NCC studies showed an association between ICSs and risk of tuberculosis and mycobacterial disease. There was a strong association between ICS use and local disorders such as oral candidiasis and dysphonia. The association between ICSs and the risk of diabetes and fractures was less clear and appeared significant only at high doses of ICSs.Since most patients with COPD are elderly and with frequent comorbidities, an adequate risk-benefit balance is crucial for the indication of ICSs.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Both authors contributed equally and are considered first authors
| | - Ariadna Auladell-Rispau
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Both authors contributed equally and are considered first authors
| | - Mònica Monteagudo
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Medicine Dept, Universitat Autònoma de Barcelona (UAB), Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Juan Carlos Vázquez-Niebla
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | | | - Alexa Nuñez
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gerard Urrútia
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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16
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Bourbeau J, Bafadhel M, Barnes NC, Compton C, Di Boscio V, Lipson DA, Jones PW, Martin N, Weiss G, Halpin DMG. Benefit/Risk Profile of Single-Inhaler Triple Therapy in COPD. Int J Chron Obstruct Pulmon Dis 2021; 16:499-517. [PMID: 33688176 PMCID: PMC7935340 DOI: 10.2147/copd.s291967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/07/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with major healthcare and socioeconomic burdens. International consortia recommend a personalized approach to treatment and management that aims to reduce both symptom burden and the risk of exacerbations. Recent clinical trials have investigated single-inhaler triple therapy (SITT) with a long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA), and inhaled corticosteroid (ICS) for patients with symptomatic COPD. Here, we review evidence from randomized controlled trials showing the benefits of SITT and weigh these against the reported risk of pneumonia with ICS use. We highlight the challenges associated with cross-trial comparisons of benefit/risk, discuss blood eosinophils as a marker of ICS responsiveness, and summarize current treatment recommendations and the position of SITT in the management of COPD, including potential advantages in terms of improving patient adherence. Evidence from trials of SITT versus dual therapies in symptomatic patients with moderate to very severe airflow limitation and increased risk of exacerbations shows benefits in lung function and patient-reported outcomes. Moreover, the key benefits reported with SITT are significant reductions in exacerbations and hospitalizations, with data also suggesting reduced all-cause mortality. These benefits outweigh the ICS-class effect of higher incidence of study-reported pneumonia compared with LAMA/LABA. Important differences in trial design, baseline population characteristics, such as exacerbation history, and assessment of outcomes, have significant implications for interpreting data from cross-trial comparisons. Current understanding interprets the blood eosinophil count as a continuum that can help predict response to ICS and has utility alongside other clinical factors to aid treatment decision-making. We conclude that treatment decisions in COPD should be guided by an approach that considers benefit versus risk, with early optimization of treatment essential for maximizing long-term benefits and patient outcomes.
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Affiliation(s)
- Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mona Bafadhel
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Neil C Barnes
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- William Harvey Institute, Bart’s and the London School of Medicine and Dentistry, London, UK
| | - Chris Compton
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | | | - David A Lipson
- Clinical Sciences, GlaxoSmithKline, Collegeville, PA, USA
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul W Jones
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- Institute of Infection and Immunity, St George’s, University of London, London, UK
| | - Neil Martin
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- University of Leicester, Leicester, UK
| | - Gudrun Weiss
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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17
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Zhudenkov K, Palmér R, Jauhiainen A, Helmlinger G, Stepanov O, Peskov K, Eriksson UG, Wählby Hamrén U. Longitudinal FEV 1 and Exacerbation Risk in COPD: Quantifying the Association Using Joint Modelling. Int J Chron Obstruct Pulmon Dis 2021; 16:101-111. [PMID: 33488073 PMCID: PMC7815071 DOI: 10.2147/copd.s284720] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/30/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Lung function, measured as forced expiratory volume in one second (FEV1), and exacerbations are two endpoints evaluated in chronic obstructive pulmonary disease (COPD) clinical trials. Joint analysis of these endpoints could potentially increase statistical power and enable assessment of efficacy in shorter and smaller clinical trials. OBJECTIVE To evaluate joint modelling as a tool for analyzing treatment effects in COPD clinical trials by quantifying the association between longitudinal improvements in FEV1 and exacerbation risk reduction. METHODS A joint model of longitudinal FEV1 and exacerbation risk was developed based on patient-level data from a Phase III clinical study in moderate-to-severe COPD (1740 patients), evaluating efficacy of fixed-dose combinations of a long-acting bronchodilator, formoterol, and an inhaled corticosteroid, budesonide. Two additional studies (1604 and 1042 patients) were used for external model validation and parameter re-estimation. RESULTS A significant (p<0.0001) association between FEV1 and exacerbation risk was estimated, with an approximate 10% reduction in exacerbation risk per 100 mL improvement in FEV1, consistent across trials and treatment arms. The risk reduction associated with improvements in FEV1 was relatively small compared to the overall exacerbation risk reduction for treatment arms including budesonide (10-15% per 160 µg budesonide). High baseline breathlessness score and previous history of exacerbations also influenced the risk of exacerbation. CONCLUSION Joint modelling can be used to co-analyze longitudinal FEV1 and exacerbation data in COPD clinical trials. The association between the endpoints was consistent and appeared unrelated to treatment mechanism, suggesting that improved lung function is indicative of an exacerbation risk reduction. The risk reduction associated with improved FEV1 was, however, generally small and no major impact on exacerbation trial design can be expected based on FEV1 alone. Further exploration with other longitudinal endpoints should be considered to further evaluate the use of joint modelling in analyzing COPD clinical trials.
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Affiliation(s)
| | - Robert Palmér
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Alexandra Jauhiainen
- BioPharma Early Biometrics and Statistical Innovation, Data Science & AI, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Gabriel Helmlinger
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Boston, MA, USA
- Clinical Pharmacology, Toxicology, Quantitative Sciences, Obsidian Therapeutics, Cambridge, MA, USA
| | | | - Kirill Peskov
- M&S Decisions LLC, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health, Moscow, Russia
| | - Ulf G Eriksson
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulrika Wählby Hamrén
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
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18
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Lodise TP, Li J, Gandhi HN, O'Brien G, Sethi S. Intraclass Difference in Pneumonia Risk with Fluticasone and Budesonide in COPD: A Systematic Review of Evidence from Direct-Comparison Studies. Int J Chron Obstruct Pulmon Dis 2020; 15:2889-2900. [PMID: 33204085 PMCID: PMC7667513 DOI: 10.2147/copd.s269637] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/23/2020] [Indexed: 12/13/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) are widely used and recommended to treat chronic obstructive pulmonary disease (COPD). While generally considered safe, several studies demonstrated an increased risk of pneumonia with the use of ICS in COPD patients. Although all ICS indicated for COPD carry the class labeling warning of increased pneumonia risk, evidence suggests an intraclass difference in the risk of pneumonia between inhaled budesonide and fluticasone. To date, systematic reviews of direct-comparison studies have not been performed to assess if an intraclass difference exists. Research Question This review investigated whether there is an intraclass difference in risk of pneumonia between inhaled fluticasone and budesonide, the 2 most commonly used ICS in COPD. Study Design and Methods A search of the medical literature was conducted in PubMed and Embase for the time period of 01/01/69–05/31/19. The search strategy combined terms that defined the patient/disease type, exposures, outcome, and the study/publication type. Descriptive and comparative statistics reported for fluticasone- and budesonide-containing products in each study, including data for pneumonia event subgroups, were extracted and reported by dose, seriousness, or practice setting. Controlled clinical trials and observational studies meeting the inclusion criteria were assessed for methodologic quality by using the appropriate tool from the list of study quality assessment tools developed by the National Institutes of Health. Results The summary relative risk (RR) ratio across 5 included studies (57,199 patients) was 1.13 (95% CI: 1.09–1.19), representing a 13.5% increased risk of pneumonia among fluticasone users compared to budesonide users. Similarly, summary RR ratio for serious pneumonia implied a 14.4% increased risk of serious pneumonia among fluticasone users compared to budesonide users (pooled RR: 1.14; 95% CI: 1.09–1.20). Interpretation There is likely a clinically important intraclass difference in the risk of pneumonia between fluticasone- and budesonide-containing inhaled medications in COPD.
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Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College Pharmacy and Health Sciences, Albany, NY, USA
| | - Jingyi Li
- Global Medical Affairs, AstraZeneca, Gaithersburg, MD, USA
| | | | - Gerald O'Brien
- US Respiratory Medical, AstraZeneca, Wilmington, DE, USA
| | - Sanjay Sethi
- Department of Medicine, University of Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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19
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Chen H, Feng Y, Wang K, Yang J, Du Y. Association between inhaled corticosteroids and upper respiratory tract infection in patients with chronic obstructive pulmonary disease: a meta-analysis of randomized controlled trials. BMC Pulm Med 2020; 20:282. [PMID: 33115481 PMCID: PMC7594481 DOI: 10.1186/s12890-020-01315-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 10/15/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We aimed to assess the association between inhaled corticosteroids (ICSs) and the risk of upper respiratory tract infection (URTI) in patients with chronic obstructive pulmonary disease (COPD). METHODS PubMed, Embase, Cochrane Library and Clinical Trials.gov were searched from inception to October 2019. Randomized controlled trials (RCTs) of any ICSs vs control for COPD with reporting of URTI as an adverse event were included. The study was registered with PROSPERO prospectively (#CRD42020153134). RESULTS Seventeen RCTs (20,478 patients) were included. ICSs significantly increased the risk of URTI in COPD patients (RR, 1.13; 95% CI 1.03-1.24; P = 0.01; heterogeneity: I2 = 7%). Futher subgroup analyses suggested that short-term use of ICSs increased the risk of URTI (RR, 1.29; 95% CI 1.06-1.56; P = 0.01; heterogeneity: I2 = 14%) but not for long-term use (RR, 1.08; 95% CI 0.97-1.2; P = 0.14; heterogeneity: I2 = 0%). Short-term use of high-dose fluticasone increased the risk of URTI (RR, 1.33; 95% CI 1.03-1.71; P = 0.03; heterogeneity: I2 = 0%) but not for long-term use (RR, 1.12; 95% CI 0.97-1.29; P = 0.13; heterogeneity: I2 = 50%). Medium-dose (RR, 0.97; 95% CI 0.71-1.32; P = 0.84; heterogeneity: I2 = 0%) and low-dose (RR, 1.39; 95% CI 0.92-2.1; P = 0.12; heterogeneity: I2 = 30%) fluticasone did not increase the risk of URTI regardless of duration. Neither mometasone (RR, 1.05; 95% CI 0.87-1.26; P = 0.61; heterogeneity: I2 = 0%) nor budesonide (RR, 1.08; 95% CI 0.77-1.5; P = 0.67; heterogeneity: I2 = 46%) increased the risk of URTI, regardless of dosage or duration. CONCLUSIONS Long-term use of ICSs does not increase the risk of URTI in patients with COPD. Short-term use of high-dose fluticasone increases the risk of URTI in patients with COPD, but not mometasone or budesonide.
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Affiliation(s)
- Hong Chen
- Department of Infectious Disease, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu, 610017, China.
| | - Yulin Feng
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Ke Wang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Jing Yang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Yuejun Du
- Department of Infectious Disease, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu, 610017, China
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20
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Abstract
Inhaled corticosteroids (ICSs), when used in combination with long-acting bronchodilators, reduce the risk of exacerbations and improve health-related quality of life in patients with chronic obstructive pulmonary disease (COPD) compared with bronchodilator or ICS therapy alone. Potential side effects of ICSs include adverse effects on glycemic control, bone density, cataract formation, skin changes, oral candidiasis, and pulmonary infections. Pneumonia is observed at increased rates in COPD patients, in particular those with greater airflow limitation, low body mass index, advanced age, and male gender, and ICSs may increase this risk. Risk assessment is essential in selecting appropriate patients for ICS-containing therapy.
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21
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COPDCompEx: A novel composite endpoint for COPD exacerbations to enable faster clinical development. Respir Med 2020; 173:106175. [PMID: 33032168 DOI: 10.1016/j.rmed.2020.106175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Frequency of moderate and severe chronic obstructive pulmonary disease exacerbations is an important endpoint in clinical trials, but makes them large and lengthy when powered to evaluate it. We aimed to develop a composite endpoint (COPDCompEx) that could predict treatment effect on exacerbations, enabling the design of shorter early phase clinical trials requiring fewer patients. METHODS In this post hoc analysis, data from 20 randomized controlled trials were used to develop and test COPDCompEx. Diary events were tested against predefined threshold values for peak expiratory flow, reliever medication use, and symptoms. A COPDCompEx event was defined as first occurrence of a diary event, a moderate or severe exacerbation, or a study dropout. Ratios of event frequency, treatment effect and future trial sample size were compared between COPDCompEx and moderate and severe exacerbations. FINDINGS At 3 months, the proportion of patients experiencing COPDCompEx events increased over 3-fold versus exacerbations alone. All components contributed to COPDCompEx event rate. Treatment effects at 3 months were closely matched between COPDCompEx and exacerbations, and the large net gain in power substantially reduced the required sample size. INTERPRETATION COPDCompEx may be used to predict treatment effect on moderate and severe exacerbations of chronic obstructive pulmonary disease. This may enable the design of shorter Phase 2 clinical trials requiring fewer patients when compared with current exacerbation studies, with exacerbations as a key Phase 3 endpoint. This would, therefore, allow more efficient decision-making with reduced burden and risk to study participants.
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22
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Zhang Q, Li S, Zhou W, Yang X, Li J, Cao J. Risk of Pneumonia with Different Inhaled Corticosteroids in COPD Patients: A Meta-Analysis. COPD 2020; 17:462-469. [PMID: 32643439 DOI: 10.1080/15412555.2020.1787369] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ICS are anti-inflammatory agents which have been suggested to benefit people with worsening symptoms of COPD, by improving lung function, reducing exacerbation of disease, and enhancing overall quality of life. This systematic review and meta-analysis explored the association of the risk of pneumonia in COPD patients that were undergoing treatment using ICS alone or together with LABAs or LAMAs. PubMed, Cochrane Library and EMBASE were systematically searched through August 1, 2019; only double-blinded randomized controlled trials were eligible for this study. Eighteen randomized controlled trials were included. ICS treatment was linked to increased pneumonia incidence (RR, 1.47; 95% CI, 1.26-1.71; p < 0.001; I2 = 39.6%). Patients treated with salmeterol/fluticasone were more likely to have experience pneumonia-related adverse events than those treated using budesonide/formoterol or beclomethasone/formoterol. In subgroup analyses, pneumonia risk was found to be higher in the subgroups: >65 years old, lowest baseline forced expiratory volume in the first second of expiration (FEV1) < 50% of the predicted value, highest ICS dose, and long duration of ICS use. Furthermore, we compared fluticasone propionate with fluticasone furoate and determined that pneumonia incidence was higher in the former group and pneumonia incidence rose as doses rose in these two groups. However, no difference was observed between the budesonide and beclomethasone groups. ICS treatment was linked to an elevated pneumonia risk, different kinds of ICS lead to different rates of pneumonia.
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Affiliation(s)
- Qian Zhang
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Shuo Li
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Zhou
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Xia Yang
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinna Li
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Jie Cao
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
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23
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Król A, Palmér R, Rondeau V, Rennard S, Eriksson UG, Jauhiainen A. Improving the evaluation of COPD exacerbation treatment effects by accounting for early treatment discontinuations: a post-hoc analysis of randomized clinical trials. Respir Res 2020; 21:158. [PMID: 32571311 PMCID: PMC7310001 DOI: 10.1186/s12931-020-01419-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 06/09/2020] [Indexed: 11/28/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) clinical trials aimed at evaluating treatment effects on exacerbations often suffer from early discontinuations of randomized treatment. Treatment discontinuations imply a loss of information and should ideally be considered in the statistical analysis of trial results, particularly if the discontinuations are related to the disease or treatment itself. Here, we explore this issue by investigating (1) whether there exists an association between the risks of exacerbation and treatment discontinuation in COPD clinical trials and (2) whether disregarding this association can cause bias in exacerbation treatment effect estimates. We focus on the hypothetical estimand, i.e. the treatment effect that would have been observed had all subjects completed the trial as planned. Methods The association between exacerbation and discontinuation risks was analysed by applying a joint frailty (random effect) model – allowing for the simultaneous analysis of multiple types of correlated events – to data from five Phase III-IV COPD clinical trials. Specifically, the impact of the association on exacerbation treatment effect estimates was assessed by comparing the treatment hazard ratios of the joint frailty model to the rate/hazard ratios of two related statistical models (the negative binomial and shared frailty models), which both assume discontinuations to be unrelated to the trial outcome. The models were also compared using simulated data. Results A statistically significant (p < 0.0001), positive association between exacerbation and discontinuation risks was found in all trials. Importantly, simulations confirmed that – with such an association – models disregarding the association risk producing biased results (> 5 percentage point difference in hazard/rate ratio). For some treatment comparisons in the clinical trials, the difference in treatment effect estimates between the joint frailty and the other models was as high as 10–15 percentage points. The difference was affected by the strength of the exacerbation-discontinuation association, the population heterogeneity in exacerbation risk, and the difference in discontinuation rates between treatment arms. Conclusions We have identified an association between the risks of exacerbation and treatment discontinuation in five COPD clinical trials. We recommend using the joint frailty model to account for this association when estimating exacerbation treatment effects, particularly when targeting the hypothetical estimand.
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Affiliation(s)
- Agnieszka Król
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Robert Palmér
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Virginie Rondeau
- Biostatistics Team, INSERM CR1219, University of Bordeaux, Bordeaux, France
| | - Stephen Rennard
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK.,University of Nebraska Medical Center, Omaha, NE, USA
| | - Ulf G Eriksson
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Alexandra Jauhiainen
- BioPharma Early Biometrics and Statistical Innovation, Data Science & AI, BioPharmaceuticals R&D, AstraZeneca, Pepparedsleden 1, SE-431 83, Mölndal, Sweden.
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24
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Hanania NA, Papi A, Anzueto A, Martinez FJ, Rossman KA, Cappelletti CS, Duncan EA, Nyberg JS, Dorinsky PM. Efficacy and safety of two doses of budesonide/formoterol fumarate metered dose inhaler in COPD. ERJ Open Res 2020; 6:00187-2019. [PMID: 32363206 PMCID: PMC7184113 DOI: 10.1183/23120541.00187-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/19/2020] [Indexed: 11/09/2022] Open
Abstract
Inhaled corticosteroid/long-acting β2-agonist combination therapy is a recommended treatment option for patients with chronic obstructive pulmonary disease (COPD) and increased exacerbation risk, particularly those with elevated blood eosinophil levels. SOPHOS (NCT02727660) evaluated the efficacy and safety of two doses of budesonide/formoterol fumarate dihydrate metered dose inhaler (BFF MDI) versus formoterol fumarate dihydrate (FF) MDI, each delivered using co-suspension delivery technology, in patients with moderate-to-very severe COPD and a history of exacerbations. In this phase 3, randomised, double-blind, parallel-group, 12–52-week, variable length study, patients received twice-daily BFF MDI 320/10 µg or 160/10 µg, or FF MDI 10 µg. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) at week 12. Secondary and other endpoints included assessments of moderate/severe COPD exacerbations and safety. The primary analysis (modified intent-to-treat) population included 1843 patients (BFF MDI 320/10 µg, n=619; BFF MDI 160/10 µg, n=617; and FF MDI, n=607). BFF MDI 320/10 µg and 160/10 µg improved morning pre-dose trough FEV1 at week 12 versus FF MDI (least squares mean differences 34 mL [p=0.0081] and 32 mL [p=0.0134], respectively), increased time to first exacerbation (hazard ratios 0.827 [p=0.0441] and 0.803 [p=0.0198], respectively) and reduced exacerbation rate (rate ratios 0.67 [p=0.0001] and 0.71 [p=0.0010], respectively). Lung function and exacerbation benefits were driven by patients with blood eosinophil counts ≥150 cells·mm−3. The incidence of adverse events was similar, and pneumonia rates were low (≤2.4%) across treatments. SOPHOS demonstrated the efficacy and tolerability of BFF MDI 320/10 µg and 160/10 µg in patients with moderate-to-very severe COPD at increased risk of exacerbations. Co-suspension delivery technology budesonide/formoterol fumarate metered dose inhaler improve lung function and reduce exacerbation risk versus LABA monotherapy in patients with moderate to very severe COPD and an exacerbation history in the prior yearhttp://bit.ly/3aDOvru
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Affiliation(s)
- Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alberto Papi
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonio Anzueto
- Pulmonary Medicine and Critical Care, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Fernando J Martinez
- Joan and Sanford I. Weill Dept of Medicine, Weill Cornell Medicine, New York, NY, USA
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25
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Abstract
Airway inflammation is a major contributing factor in both asthma and chronic obstructive pulmonary disease (COPD) and represents an important target for treatment. Inhaled corticosteroids (ICS) as monotherapy or in combination therapy with long-acting β2-agonists or long-acting muscarinic antagonists are used extensively in the treatment of asthma and COPD. The development of ICS for their anti-inflammatory properties progressed through efforts to increase topical potency and minimise systemic potency and through advances in inhaled delivery technology. Budesonide is a potent, non-halogenated ICS that was developed in the early 1970s and is now one of the most widely used lung medicines worldwide. Inhaled budesonide's physiochemical and pharmacokinetic/pharmacodynamic properties allow it to reach a rapid and high airway efficacy due to its more balanced relationship between water solubility and lipophilicity. When absorbed from the airways and lung tissue, its moderate lipophilicity shortens systemic exposure, and its unique property of intracellular esterification acts like a sustained release mechanism within airway tissues, contributing to its airway selectivity and a low risk of adverse events. There is a large volume of clinical evidence supporting the efficacy and safety of budesonide, both alone and in combination with the fast- and long-acting β2-agonist formoterol, as maintenance therapy in patients with asthma and with COPD. The combination of budesonide/formoterol can also be used as an as-needed reliever with anti-inflammatory properties, with or without regular maintenance for asthma, a novel approach that is already approved by some country-specific regulatory authorities and currently recommended in the Global Initiative for Asthma (GINA) guidelines. Budesonide remains one of the most well-established and versatile of the inhaled anti-inflammatory drugs. This narrative review provides a clinical reappraisal of the benefit:risk profile of budesonide in the management of asthma and COPD.
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26
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Mapel DW, Roberts MH, Davis J. Budesonide/formoterol therapy: effective and appropriate use in asthma and chronic obstructive pulmonary disease. J Comp Eff Res 2020; 9:231-251. [PMID: 31983228 DOI: 10.2217/cer-2019-0161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Quality, real-world comparative effectiveness (CE) studies of asthma and chronic obstructive pulmonary disease therapy efficacy are scarce. We identified and evaluated peer-reviewed CE and appropriate-use evaluations of budesonide/formoterol combination (BFC) maintenance therapy. Materials & methods: Analyses were limited to retrospective, real-world utilization studies of BFC delivered by pressurized metered-dose inhalers. Results: In a CE study of BFC versus fluticasone/salmeterol combinations (FSC) in asthma, BFC users had fewer total exacerbations. In appropriate-use studies of asthma treatment, BFC patients were consistently more likely to meet treatment escalation recommendations. BFC comparisons with FSC or tiotropium for chronic obstructive pulmonary disease found differences in exacerbation rates and rescue inhaler use. Conclusion: We found available, good quality BFC CE and appropriate-use articles; however, all had limitations.
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Affiliation(s)
- Douglas W Mapel
- University of New Mexico College of Pharmacy, MSC09 5360, University of New Mexico, Albuquerque, NM 87131, USA.,LCF Research, 2309 Renard Place SE Ste 103, Albuquerque, NM 87106, USA
| | - Melissa H Roberts
- University of New Mexico College of Pharmacy, MSC09 5360, University of New Mexico, Albuquerque, NM 87131, USA
| | - Jill Davis
- AstraZeneca LP, 1800 Concord Pike, Wilmington, DE 19897, USA
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27
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Bafadhel M, Singh D, Jenkins C, Peterson S, Bengtsson T, Wessman P, Fagerås M. Reduced risk of clinically important deteriorations by ICS in COPD is eosinophil dependent: a pooled post-hoc analysis. Respir Res 2020; 21:17. [PMID: 31924197 PMCID: PMC6954504 DOI: 10.1186/s12931-020-1280-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinically Important Deterioration (CID) is a novel composite measure to assess treatment effect in chronic obstructive pulmonary disease (COPD). We examined the performance and utility of CID in assessing the effect of inhaled corticosteroids (ICS) in COPD. METHODS This post-hoc analysis of four budesonide/formoterol (BUD/FORM) studies comprised 3576 symptomatic moderate-to-very-severe COPD patients with a history of exacerbation. Analysis of time to first CID event (exacerbation, deterioration in forced expiratory volume in 1 second [FEV1] or worsening St George's Respiratory Questionnaire [SGRQ] score) was completed using Cox proportional hazards models. RESULTS The proportion of patients with ≥1 CID in the four studies ranged between 63 and 77% and 69-84% with BUD/FORM and FORM, respectively, with an average 25% reduced risk of CID with BUD/FORM. All components contributed to the CID event rate. Experiencing a CID during the first 3 months was associated with poorer outcomes (lung function, quality of life, symptoms and reliever use) and increased risk of later CID events. The effect of BUD/FORM versus FORM in reducing CID risk was positively associated with the blood eosinophil count. CONCLUSIONS Our findings suggest that BUD/FORM offers protective effects for CID events compared with FORM alone, with the magnitude of the effect dependent on patients' eosinophil levels. CID may be an important tool for evaluation of treatment effect in a complex, multifaceted, and progressive disease like COPD, and a valuable tool to allow for shorter and smaller future outcome predictive trials in early drug development.
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Affiliation(s)
- Mona Bafadhel
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK.
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Christine Jenkins
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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28
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Abdool-Gaffar MS, Calligaro G, Wong ML, Smith C, Lalloo UG, Koegelenberg CFN, Dheda K, Allwood BW, Goolam-Mahomed A, van Zyl-Smit RN. Management of chronic obstructive pulmonary disease-A position statement of the South African Thoracic Society: 2019 update. J Thorac Dis 2019; 11:4408-4427. [PMID: 31903229 PMCID: PMC6940223 DOI: 10.21037/jtd.2019.10.65] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 11/06/2022]
Affiliation(s)
| | - Gregory Calligaro
- Division of Pulmonology and UCT Lung Institute, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Michelle Lianne Wong
- Division of Pulmonology, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clifford Smith
- Morningside Mediclinic, Sandton, Johannesburg, South Africa
| | - Umesh Gangaram Lalloo
- Durban University of Technology, Enhancing Care Foundation and Busamed Gateway Private Hospital, Kwa Zulu-Natal, South Africa
| | | | - Keertan Dheda
- Division of Pulmonology and UCT Lung Institute, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian William Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Akhter Goolam-Mahomed
- Louis Pasteur Private Hospital and Mediclinic Pretoria Heart Hospital, Pretoria, South Africa
| | - Richard Nellis van Zyl-Smit
- Division of Pulmonology and UCT Lung Institute, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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29
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Yang M, Du Y, Chen H, Jiang D, Xu Z. Inhaled corticosteroids and risk of pneumonia in patients with chronic obstructive pulmonary disease: A meta-analysis of randomized controlled trials. Int Immunopharmacol 2019; 77:105950. [PMID: 31629940 DOI: 10.1016/j.intimp.2019.105950] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/19/2019] [Accepted: 09/29/2019] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Inhaled corticosteroids (ICS) are generally used to treat patients with chronic obstructive pulmonary disease (COPD) who suffer from repeated exacerbations. Recently, it was reported that ICS treatment increased the risk of pneumonia in COPD patients. But it is controversial.The objective of this paper is to clarify the associations between ICS treatment and the risk of pneumonia in COPD patients. METHODS PubMed, Cochrane Library, Clinical Trials.gov, and Embase were searched from February 2019 to June 2019. Randomized clinical trials (RCTs) were incorporatedthat compared ICS with non-ICS treatment on the risk of pneumonia in COPD patients. Meta-analyses were conducted by the Peto and Mantel-Haenszel approaches with corresponding 95% CIs. RESULTS Twenty-five trials (N = 49,982 subjects) were included. Pooled results demonstrated a significantly increased risk of pneumonia with ICS use in COPD patients (RR, 1.59, 95% CI, 1.33-1.90; I2 = 51%). ICS treatment also increased the risk of severe pneumonia (RR, 2.17, 95% CI, 1.47-3.22; I2 = 29%). The results of subgroup analysis based on doses of ICS were consistent with the above. However, subgroup analyses based on types of ICS revealed that fluticasone therapy was associated with an increased risk of pneumonia but not budesonide. In addition, medium- and low-doses of budesonide treatment also did not increase the risk of pneumonia. CONCLUSIONS Use of ICS increases the risk of pneumonia in patients with COPD. The above is prominent for fluticasone-containing ICSs but not for budesonide-containing ICSs.
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Affiliation(s)
- Mingjin Yang
- Respiratory Diseases Laboratory, Chengdu Second People's Hospital, Chengdu, China
| | - Yuejun Du
- Respiratory Diseases Laboratory, Chengdu Second People's Hospital, Chengdu, China
| | - Hong Chen
- Respiratory Diseases Laboratory, Chengdu Second People's Hospital, Chengdu, China
| | - Depeng Jiang
- Department of Respiratory Medicine, the Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
| | - Zhibo Xu
- Respiratory Diseases Laboratory, Chengdu Second People's Hospital, Chengdu, China.
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30
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Almagro P, Martinez-Camblor P, Soriano JB. Inhaled corticosteroids and pneumonia mortality in COPD patients. Eur Respir J 2019; 54:1901035. [PMID: 31488585 DOI: 10.1183/13993003.01035-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/30/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Pere Almagro
- Multimorbidity Patients Unit, Internal Medicine Dept, University Hospital Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | | | - Joan B Soriano
- Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, CIBERES, Instituto de Salud Carlos III, Madrid, España
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31
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Lipson DA, Barnacle H, Birk R, Brealey N, Locantore N, Lomas DA, Ludwig-Sengpiel A, Mohindra R, Tabberer M, Zhu CQ, Pascoe SJ. Reply to Morice and Hart: Increased Propensity for Pneumonia with Fluticasone in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2019; 197:1230-1231. [PMID: 29241016 DOI: 10.1164/rccm.201711-2313le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David A Lipson
- 1 GSK King of Prussia, Pennsylvania.,2 University of Pennsylvania Philadelphia, Pennsylvania
| | | | | | | | | | - David A Lomas
- 4 University College London London, United Kingdom and
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32
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Pascoe S, Barnes N, Brusselle G, Compton C, Criner GJ, Dransfield MT, Halpin DMG, Han MK, Hartley B, Lange P, Lettis S, Lipson DA, Lomas DA, Martinez FJ, Papi A, Roche N, van der Valk RJP, Wise R, Singh D. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:745-756. [PMID: 31281061 DOI: 10.1016/s2213-2600(19)30190-0] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 04/05/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous studies have highlighted a relationship between reduction in rate of exacerbations with therapies containing inhaled corticosteroids (ICS) and baseline blood eosinophil count in patients with chronic obstructive pulmonary disease (COPD). The IMPACT trial showed that once-daily single-inhaler triple therapy significantly reduced exacerbations versus dual therapies. Blood eosinophil counts and smoking status could be important modifiers of treatment response to ICS. We aimed to model these relationships and their interactions, including outcomes other than exacerbations. METHODS IMPACT was a phase 3, randomised, double-blind, parallel-group, 52-week global study comparing once-daily single-inhaler triple therapy (fluticasone furoate-umeclidinium-vilanterol) with dual inhaled therapy (fluticasone furoate-vilanterol or umeclidinium-vilanterol). Eligible patients had moderate-to-very-severe COPD and at least one moderate or severe exacerbation in the previous year. We used fractional polynomials to model continuous blood eosinophil counts. We used negative binomial regression for numbers of moderate and severe exacerbations, severe exacerbations, and pneumonia. We modelled differences at week 52 in trough FEV1, St George's Respiratory Questionnaire (SGRQ) total score, and Transition Dyspnoea Index using repeated measurements mixed effect models. IMPACT was registered with ClinicalTrials.gov, number NCT02164513. FINDINGS The magnitude of benefit of regimens containing ICS (fluticasone furoate-umeclidinium-vilanterol n=4151 and fluticasone furoate-vilanterol n=4134) in reducing rates of moderate and severe exacerbations increased in proportion with blood eosinophil count, compared with a non-ICS dual long-acting bronchodilator (umeclidinium-vilanterol n=2070). The moderate and severe exacerbation rate ratio for triple therapy versus umeclidinium-vilanterol was 0·88 (95% CI 0·74 to 1·04) at blood eosinophil count less than 90 cells per μL and 0·56 (0·47 to 0·66) at counts of 310 cells per μL or more; the corresponding rate ratio for fluticasone furoate-vilanterol versus umeclidinium-vilanterol was 1·09 (0·91 to 1·29) and 0·56 (0·47 to 0·66), respectively. Similar results were observed for FEV1, Transition Dyspnoea Index, and SGRQ total score; however, the relationship with FEV1 was less marked. At blood eosinophil counts less than 90 cells per μL and at counts of 310 cells per μL or more, the triple therapy versus umeclidinium-vilanterol treatment difference was 40 mL (95% CI 10 to 70) and 60 mL (20 to 100) for trough FEV1, -0·01 (-0·68 to 0·66) and 0·30 (-0·37 to 0·97) for Transition Dyspnoea Index score, and -0·01 (-1·81 to 1·78) and -2·78 (-4·64 to -0·92) for SGRQ total score, respectively. Smoking status modified the relationship between observed efficacy and blood eosinophil count for moderate or severe exacerbations, Transition Dyspnoea Index, and FEV1, with former smokers being more corticosteroid responsive at any eosinophil count than current smokers. INTERPRETATION This analysis of the IMPACT trial shows that assessment of blood eosinophil count and smoking status has the potential to optimise ICS use in clinical practice in patients with COPD and a history of exacerbations. FUNDING GlaxoSmithKline.
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Affiliation(s)
| | - Neil Barnes
- GlaxoSmithKline, Brentford, UK; Barts and the London School of Medicine and Dentistry, London, UK
| | | | | | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - MeiLan K Han
- University of Michigan, Pulmonary & Critical Care, Ann Arbor, MI, USA
| | | | - Peter Lange
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark; Medical Department, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - David A Lipson
- GlaxoSmithKline, Collegeville, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Lomas
- UCL Respiratory, University College London, Gower Street, London, UK
| | | | - Alberto Papi
- Research Centre on Asthma and COPD, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Nicolas Roche
- Pneumologie, Cochin Hospital AP-HP, University Paris Descartes, Paris, France
| | | | - Robert Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Dave Singh
- University of Manchester, Manchester, UK
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Russo P, Tomino C, Santoro A, Prinzi G, Proietti S, Kisialiou A, Cardaci V, Fini M, Magnani M, Collacchi F, Provinciali M, Giacconi R, Bonassi S, Malavolta M. FKBP5 rs4713916: A Potential Genetic Predictor of Interindividual Different Response to Inhaled Corticosteroids in Patients with Chronic Obstructive Pulmonary Disease in a Real-Life Setting. Int J Mol Sci 2019; 20:ijms20082024. [PMID: 31022961 PMCID: PMC6514776 DOI: 10.3390/ijms20082024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/02/2019] [Accepted: 04/19/2019] [Indexed: 01/20/2023] Open
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a common, preventable, and manageable lung disease characterized by large heterogeneity in disease presentation and grades impairment. Inhaled corticosteroids (ICS) are commonly used to manage COPD/COPD-exacerbation. The patient's response is characterized by interindividual variability without disease progression/survival modification. Objectives: We hypothesize that a therapeutic intervention may be more effective if single nucleotide polymorphisms (SNPs) are investigated. Methods: In 71 COPD patients under pulmonary rehabilitation, a small number of powerful SNPs, selected according to current literature, were analyzed; namely the glucocorticoid receptor gene NR3C1 (rs6190/rs6189/rs41423247), the glucocorticoid-induced transcript 1 gene (GLCCI1 rs37972), and the related co-chaperone FKBP5 gene (rs4713916). MDR1 rs2032582 was also evaluated. Lung function outcomes were assessed. Results: A significant association with functional outcomes, namely FEV1 (forced expiration volume/one second) and 6MWD (six-minutes walking distance), was found for rs4713916 and weakly for rs37972. The genotype rs4713916(GA) and, in a lesser extent, the genotype rs37972(TT), were more favorable than the wild-type. Conclusions: Our study supports a possible picture of pharmacogenomic control for COPD intervention. rs4713916 and, possibly, rs37972 may be useful predictors of clinical outcome. These results may help to tailor an optimal dose for individual COPD patients based on their genetic makeup.
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Affiliation(s)
- Patrizia Russo
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, Via di Valcannuta, 247 00166 Rome, Italy.
| | - Carlo Tomino
- Scientific Direction, IRCCS San Raffaele Pisana, 0166 Rome, Italy.
| | - Alessia Santoro
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, Via di Valcannuta, 247 00166 Rome, Italy.
| | - Giulia Prinzi
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, Via di Valcannuta, 247 00166 Rome, Italy.
| | | | - Aliaksei Kisialiou
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, Via di Valcannuta, 247 00166 Rome, Italy.
| | - Vittorio Cardaci
- Pulmonary Rehabilitation, IRCCS San Raffaele Pisana, 00166 Rome, Italy.
| | - Massimo Fini
- Scientific Direction, IRCCS San Raffaele Pisana, 0166 Rome, Italy.
| | - Mauro Magnani
- Department of Biomolecular Science-Section of Biotechnology, University of Urbino "Carlo Bo", 61032 Fano, Italy.
| | | | - Mauro Provinciali
- Advanced Technology Center for Aging Research, Scientific Technological Area, IRCCS INRCA, 60124 Ancona, Italy.
| | - Robertina Giacconi
- Advanced Technology Center for Aging Research, Scientific Technological Area, IRCCS INRCA, 60124 Ancona, Italy.
| | - Stefano Bonassi
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, Via di Valcannuta, 247 00166 Rome, Italy.
| | - Marco Malavolta
- Advanced Technology Center for Aging Research, Scientific Technological Area, IRCCS INRCA, 60124 Ancona, Italy.
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Dedman D, Coton SJ, Ghosh RE, Meeraus W, Crim C, Harvey C, Amelio J, Landis SH. Treatment Patterns of New Users of Fluticasone Furoate/Vilanterol in Asthma and COPD in UK Primary Care: Retrospective Cohort Study. Pulm Ther 2019; 5:81-95. [PMID: 32026429 PMCID: PMC6967316 DOI: 10.1007/s41030-019-0092-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction This retrospective database study explored treatment patterns and potential off-label prescribing among patients newly prescribed fluticasone furoate/vilanterol (FF/VI) in a UK primary care setting. Methods In Europe, FF/VI is approved in two strengths: 100/25 µg for adults with chronic obstructive pulmonary disease (COPD) and 100/25 µg or 200/25 µg for treatment of asthma in patients aged 12 or older. Using electronic health records from the Clinical Practice Research Datalink, new users of FF/VI or other inhaled corticosteroid/long-acting beta-agonist fixed-dose combination products were identified and classified into one of three groups: COPD diagnosis, asthma diagnosis, and other diagnosis (not COPD or asthma). Results During 2014–2015, 4373 patients initiated FF/VI: 3380 on FF/VI 100/25 (65% in the COPD diagnosis group) and 993 on FF/VI 200/25 (51% in the asthma diagnosis group). During up to 12 months of follow-up, the median number (interquartile range) of prescriptions of the index strength issued per patient was 7 (2–8) for FF/VI 100/25 and 5 (2–8) for FF/VI 200/25; most new users did not change from the index strength prescribed (93.0% COPD; 89.7% asthma, of all patients initiating treatment with FF/VI). Potential off-label FF/VI prescribing in children < 12 years old was rare (< 0.29% in the combined asthma and other diagnosis groups), and up to one in five new users of FF/VI with COPD were potentially prescribed FF/VI 200/25 off-label during the study period. Much of the potential off-label prescribing in COPD occurred in patients with a history of asthma, those presenting with greater disease severity, and/or prior treatment with high-dose steroids. Conclusions The prescription of FF/VI is rare in children under 12 years of age in the UK, according to our findings, but up to one in five COPD patients in the UK may have been prescribed FF/VI 200/25, some of which may have been off-label. Funding This study was funded by GlaxoSmithKline plc (study 205052). Study Registration GlaxoSmithKline plc Clinical Trial Registry study number 205052. Electronic supplementary material The online version of this article (10.1007/s41030-019-0092-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Dedman
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK.
| | - Sonia J Coton
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Rebecca E Ghosh
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Wilhelmine Meeraus
- GlaxoSmithKline plc, Epidemiology, Value Evidence and Outcomes, Stockley Park, Uxbridge, UK
| | - Courtney Crim
- GlaxoSmithKline plc, Research and Development, Research Triangle Park, NC, USA
| | - Catherine Harvey
- GlaxoSmithKline plc, Global Clinical Safety and Pharmacovigilance, Stockley Park, Uxbridge, UK
| | - Justyna Amelio
- GlaxoSmithKline plc, Epidemiology, Value Evidence and Outcomes, Stevenage, UK
| | - Sarah H Landis
- GlaxoSmithKline plc, Epidemiology, Value Evidence and Outcomes, Stockley Park, Uxbridge, UK
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Ferraro M, Di Vincenzo S, Dino P, Bucchieri S, Cipollina C, Gjomarkaj M, Pace E. Budesonide, Aclidinium and Formoterol in combination limit inflammaging processes in bronchial epithelial cells exposed to cigarette smoke. Exp Gerontol 2019; 118:78-87. [PMID: 30659954 DOI: 10.1016/j.exger.2019.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/21/2018] [Accepted: 01/14/2019] [Indexed: 12/31/2022]
Abstract
Inflammation and cellular senescence (also called inflammaging) are involved in the pathogenesis of premature lung aging, a key driver of chronic obstructive pulmonary disease (COPD). Downregulation of histone deacetylases and FoxO3 expression, activation of the ERK 1/2 pathway and IL-8 increase are hallmarks of lung inflammaging. The effects of Budesonide (BUD), Aclidinium (ACL) and Formoterol (FO) on lung inflammaging are unknown. This study was aimed to assess the effects of BUD, ACL and FO in bronchial epithelial cells exposed to cigarette smoke extract (CSE) by evaluating: a) Expression of TLR4 and survivin and LPS binding by flow cytometry; b) expression of HDAC2, HDAC3, SIRT1 and FoxO3 and activation of the ERK 1/2 pathway by western blot; c) IL-8 mRNA levels and release by Real Time-PCR and ELISA, respectively. Reported results show that CSE increased TLR4 and survivin, LPS binding, ERK 1/2 activation, IL-8 release and mRNA levels but decreased SIRT1, HDAC2, HDAC3 and FoxO3 nuclear expression. Combined therapy with BUD, ACL and FO counteracted the effects of CSE on LPS binding, FoxO3 nuclear expression, ERK 1/2 activation, survivin and IL-8 release and mRNA levels. These findings suggest a new role of combination therapy with BUD, ACL and FO in counteracting inflammaging processes induced by cigarette smoke exposure.
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Affiliation(s)
- M Ferraro
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - S Di Vincenzo
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - P Dino
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - S Bucchieri
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - C Cipollina
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy; Fondazione Ri.MED, Palermo, Italy
| | - M Gjomarkaj
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - E Pace
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy.
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36
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Tang B, Wang J, Luo LL, Li QG, Huang D. Risks of budesonide/formoterol for the treatment of stable COPD: a meta-analysis. Int J Chron Obstruct Pulmon Dis 2019; 14:757-766. [PMID: 31015757 PMCID: PMC6448539 DOI: 10.2147/copd.s192166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Purpose The aim of this study was to investigate the comparative risks of budesonide/formoterol, versus placebo or monotherapies, for the treatment of patients with stable COPD. Materials and methods We undertook a systematic search of the literature in PubMed, Embase, and the Cochrane Central Register of Controlled Trials, for randomized controlled trials (RCTs) comparing budesonide/formoterol with control regimens for the treatment of patients with stable COPD and at least 12 weeks of follow-up, meeting the inclusion criteria. Studies were reviewed, and OR with corresponding 95% CI was used to pool the results. Results A total of eight studies involving 9,254 patients met the inclusion criteria of this meta-analysis. Compared with placebo, combination therapy with budesonide/formoterol was associated with a significantly higher risk of adverse effects including oral candidiasis (OR: 3.09, 95% CI: 1.95–4.91) and dysphonia (OR: 2.76, 95% CI: 1.40–5.44), but not pneumonia (OR: 0.94, 95% CI: 0.64–1.37) or bronchitis (OR: 1.36, 95% CI: 0.95–1.95). A similar pattern was also evident for the comparison of formoterol with budesonide/formoterol, with increased occurrence of oral candidiasis (OR: 2.72, 95% CI: 1.33–5.58) and dysphonia (OR: 4.13, 95% CI: 1.95–8.76); however, there were no significant differences in pneumonia (OR: 1.31, 95% CI: 0.98–1.74) or bronchitis (OR: 1.05, 95% CI: 0.83–1.31). In contrast, compared with budesonide, combined budesonide/formoterol was associated with similar risks of adverse effects, including pneumonia (OR: 1.20, 95% CI: 0.60–2.39), bronchitis (OR: 0.95, 95% CI: 0.41–2.20), oral candidiasis (OR: 0.79, 95% CI: 0.41–1.53), and dysphonia (OR: 1.00, 95% CI: 0.40–2.47). Conclusion Combination therapy does not cause more adverse events, including pneumonia and bronchitis, than control (placebo, formoterol, or budesonide) treatment in patients with stable COPD, while there were higher risks of oral candidiasis and dysphonia compared with the non-inhaled corticosteroid group (placebo, formoterol).
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Affiliation(s)
- Bin Tang
- Department of Respiratory Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, No. 92 Aiguo Road, Nanchang, 330006, Jiangxi, China,
| | - Jun Wang
- Department of Respiratory Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, No. 92 Aiguo Road, Nanchang, 330006, Jiangxi, China,
| | - Lin-Lin Luo
- Department of Respiratory Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, No. 92 Aiguo Road, Nanchang, 330006, Jiangxi, China,
| | - Qiu-Gen Li
- Department of Respiratory Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, No. 92 Aiguo Road, Nanchang, 330006, Jiangxi, China,
| | - Dan Huang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi, China,
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37
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Cosío BG, Dacal D, Pérez de Llano L. Asthma-COPD overlap: identification and optimal treatment. Ther Adv Respir Dis 2019; 12:1753466618805662. [PMID: 30336736 PMCID: PMC6196614 DOI: 10.1177/1753466618805662] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are both highly prevalent conditions that can coexist in the same individual: the so-called ‘asthma -COPD overlap’ (ACO). Its prevalence and prognosis vary widely depending on how ACO is defined in each publication, the severity of bronchial obstruction of patients included and the treatment they are receiving. Although there is a lack of evidence about the biology of ACO, the overlap of both diseases should express a mixture of a Th1 inflammatory pattern (characteristic of COPD) and a Th2 signature (characteristic of asthma). In this review we support a novel algorithm for ACO diagnosis proposed by the Spanish Respiratory Society (SEPAR), based on a sequential evaluation that considers: (a) the presence of chronic airflow limitation in a smoker or ex-smoker patient ⩾35 years old; (b) a current diagnosis of asthma; and (c) the existence of a very positive bronchodilator test (PBT; ⩾15% and ⩾400 ml) or the presence of eosinophilia in blood (⩾300 eosinophils/μl). This algorithm can identify those patients who may benefit from a treatment with inhaled corticosteroids (ICSs) and maybe from biological drugs in a near future. In addition, it is easily applicable in clinical practice. The major disadvantage is that it groups patients with very different characteristics under the ACO’s umbrella. In view of this heterogeneity, we recommend a strategy of defining specific and measurable therapeutic objectives for every single patient and identifying the traits that can be treated to achieve those objectives.
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Affiliation(s)
- Borja G. Cosío
- Department of Respiratory Medicine, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - David Dacal
- Department of Respiratory Medicine, Hospital Arquitecto Marcide, Ferrol, Spain
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38
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Tang B, Wang J, Luo LL, Li QG, Huang D. Comparative Efficacy of Budesonide/Formoterol with Budesonide, Formoterol or Placebo for Stable Chronic Obstructive Pulmonary Disease: A Meta-Analysis. Med Sci Monit 2019; 25:1155-1163. [PMID: 30747109 PMCID: PMC6380161 DOI: 10.12659/msm.912033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/12/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The 2018 Global Initiative for Chronic Obstructive Lung Disease publication suggested that the combination of bronchodilator therapy of inhaled glucocorticoid/long-acting β₂ adrenoceptor agonist is more effective in improving pulmonary function and health status in the treatment of patients with acute exacerbations than the individual components; however, it is not known whether this also the case for stable chronic obstructive pulmonary disease (COPD). The purpose of this meta-analysis was to evaluate the effectiveness of budesonide/formoterol in the maintenance and relief therapy of patients with stable COPD. MATERIAL AND METHODS An electronic search of the literature in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was undertaken to identify published randomized controlled trials (RCTs) of ≥12 weeks duration comparing the budesonide/formoterol, with budesonide, formoterol, or placebo in the treatment of patients with stable COPD. The identified RCTs were reviewed. The mean difference (MD) with corresponding 95% confidence interval (CI) was used to pool the results. RESULTS Seven high quality studies with RCTs met the inclusion criteria for meta-analysis. Compared with budesonide alone, the combination therapy of budesonide/formoterol showed significant improvement in the following spirometric indices: pre-dose forced expiratory volume in 1 second (FEV₁) (SMD: 0.26, 95% CI: 0.18, 0.34; P=0.000). In addition, versus formoterol alone, budesonide/formoterol was associated with a significant increase in pre-dose FEV₁ (SMD: 0.12, 95% CI: 0.07, 0.17; P=0.000). A similar pattern was also evident in the comparison to placebo, where budesonide/formoterol yielded greater increase in pre-dose FEV₁ (SMD: 0.24, 95% CI: 0.18, 0.30; P=0.000). Moreover, compared with other controls, the combination of budesonide-formoterol significantly improved morning peak expiratory flow and evening peak expiratory flow, significantly reduced the total score of St. George's Respiratory Questionnaire. CONCLUSIONS For stable COPD patients, compared with controls (monocomponents or placebo), budesonide/formoterol improved pulmonary function and health status. Future larger long-term RCTs are warranted to assess the beneficial clinical efficacy of budesonide/formoterol in COPD patients.
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Affiliation(s)
- Bin Tang
- School of Medicine, Nanchang University, Nanchang, Jiangxi, P.R. China
- Department of Respiratory Medicine, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, P.R. China
| | - Jun Wang
- Department of Respiratory Medicine, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, P.R. China
| | - Lin-lin Luo
- Department of Respiratory Medicine, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, P.R. China
| | - Qiu-gen Li
- School of Medicine, Nanchang University, Nanchang, Jiangxi, P.R. China
- Department of Respiratory Medicine, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, P.R. China
| | - Dan Huang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
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39
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Huang K, Guo Y, Kang J, An L, Zheng Z, Ma L, Peng L, Wang H, Su R, Itoh Y, Wang C. The efficacy of adding budesonide/formoterol to ipratropium plus theophylline in managing severe chronic obstructive pulmonary disease: an open-label, randomized study in China. Ther Adv Respir Dis 2019; 13:1753466619853500. [PMID: 31240995 PMCID: PMC6595664 DOI: 10.1177/1753466619853500] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/23/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients diagnosed with chronic obstructive pulmonary disease (COPD) in China are commonly prescribed ipratropium plus theophylline (I+T) therapy. Studies have shown that an inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) combination is also efficacious in reducing symptoms and exacerbations. This study evaluated the efficacy and tolerability of adding budesonide/formoterol (BUD/FORM) to I+T in Chinese patients with severe COPD. METHODS A randomized, parallel-group, open-label, multicenter phase IV study (Clinical Trials.gov identifier: NCT01415518) was conducted in China. Patients received either BUD/FORM (160/4.5 µg; two inhalations twice daily [bid] via Turbuhaler®) + I (20 µg per inhalation, two inhalations four times daily) + T (100 mg bid) or I+T alone for 12 weeks. The primary efficacy variable was change from baseline in predose forced expiratory volume in 1 s (FEV1). RESULTS A total of 584 patients were randomized equally between treatment groups. At the end of the study, the BUD/FORM plus I+T group displayed significant improvements in predose FEV1 versus the I+T group (between-group difference 6.9%; 95% confidence interval [CI]: 4.3, 9.6; p < 0.0001). Forced vital capacity, inspiratory capacity, peak expiratory flow and health-related quality of life (HRQoL) scores were significantly improved (all p < 0.0001) and exacerbation frequency was reduced (43.5% reduction; rate ratio 0.565, 95% CI 0.325, 0.981; p = 0.0425) with BUD/FORM plus I+T versus I+T alone. CONCLUSION Patients with severe COPD in China treated with BUD/FORM plus I+T showed significant improvements in lung function and HRQoL and a reduction in exacerbations compared with I+T alone. Both treatments were well tolerated and no safety concerns were noted. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Kewu Huang
- Department of Pulmonary and Critical Care
Medicine, Beijing Chao-Yang Hospital, Capital Medical University,
China
- Beijing Institute of Respiratory Medicine,
China
| | - Yanfei Guo
- Department of Pulmonary and Critical Care
Medicine, Beijing Hospital, Ministry of Health, Dongdan, China
| | - Jian Kang
- The First Hospital of China Medical University,
Heping, Shenyang, China
| | - Li An
- Department of Pulmonary and Critical Care
Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing,
China
- Beijing Institute of Respiratory Medicine,
China
| | - Zeguang Zheng
- The First Affiliated Hospital of Guangzhou
Medical University, Yuexiu, China
| | - Lijun Ma
- Henan Provincial People’s Hospital, Zhengzhou,
China
| | - Liping Peng
- Jilin University First Hospital, Changchun,
China
| | - Hongyang Wang
- Hebei United University Affiliated Hospital,
Tangshan, China
| | - Rong Su
- Global Medicines Development, AstraZeneca,
Shanghai, China
| | | | - Chen Wang
- Department of Pulmonary and Critical Care
Medicine, Beijing Hospital, China
- Department of Pulmonary and Critical Care
Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital,
Beijing, China
- National Clinical Research Center for
Respiratory Diseases, Beijing, China
- Department of Respiratory Medicine, Capital
Medical University, Beijing, China
- Chinese Academy of Medical Sciences and Peking
Union Medical College, Beijing, China
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40
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Agusti A, Fabbri LM, Singh D, Vestbo J, Celli B, Franssen FME, Rabe KF, Papi A. Inhaled corticosteroids in COPD: friend or foe? Eur Respir J 2018; 52:13993003.01219-2018. [PMID: 30190269 DOI: 10.1183/13993003.01219-2018] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/23/2018] [Indexed: 12/28/2022]
Abstract
The efficacy, safety and positioning of inhaled corticosteroids (ICS) in the treatment of patients with chronic obstructive pulmonary disease (COPD) is much debated, since it can result in clear clinical benefits in some patients ("friend") but can be ineffective or even associated with undesired side effects, e.g. pneumonia, in others ("foe"). After critically reviewing the evidence for and against ICS treatment in patients with COPD, we propose that: 1) ICS should not be used as a single, stand-alone therapy in COPD; 2) patients most likely to benefit from the addition of ICS to long-acting bronchodilators include those with history of multiple or severe exacerbations despite appropriate maintenance bronchodilator use, particularly if blood eosinophils are >300 cells·µL-1, and those with a history of and/or concomitant asthma; and 3) the risk of pneumonia in COPD patients using ICS is higher in those with older age, lower body mass index (BMI), greater overall fragility, receiving higher ICS doses and those with blood eosinophils <100 cells·µL-1 All these factors must be carefully considered and balanced in any individual COPD patient before adding ICS to her/his maintenance bronchodilator treatment. Further research is needed to clarify some of these issues and firmly establish these recommendations.
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Affiliation(s)
- Alvar Agusti
- Respiratory Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBER Enfermedades Respiratorias, Spain
| | - Leonardo M Fabbri
- Dept of Medicine, University of Ferrara, Ferrara, Italy.,COPD Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dave Singh
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,Medicines Evaluation Unit, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Bartolome Celli
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Frits M E Franssen
- Dept of Research and Education, CIRO, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Hospital, Maastricht, The Netherlands
| | - Klaus F Rabe
- LungenClinic Großhansdorf, member of the German Center for Lung Research (DZL), Großhansdorf, Germany.,Christian Albrechts Universität Kiel, member of the German Center for Lung Research (DZL), Kiel, Germany
| | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
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41
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Oba Y, Keeney E, Ghatehorde N, Dias S. Dual combination therapy versus long-acting bronchodilators alone for chronic obstructive pulmonary disease (COPD): a systematic review and network meta-analysis. Cochrane Database Syst Rev 2018; 12:CD012620. [PMID: 30521694 PMCID: PMC6517098 DOI: 10.1002/14651858.cd012620.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Long-acting bronchodilators such as long-acting β-agonist (LABA), long-acting muscarinic antagonist (LAMA), and LABA/inhaled corticosteroid (ICS) combinations have been used in people with moderate to severe chronic obstructive pulmonary disease (COPD) to control symptoms such as dyspnoea and cough, and prevent exacerbations. A number of LABA/LAMA combinations are now available for clinical use in COPD. However, it is not clear which group of above mentioned inhalers is most effective or if any specific formulation works better than the others within the same group or class. OBJECTIVES To compare the efficacy and safety of available formulations from four different groups of inhalers (i.e. LABA/LAMA combination, LABA/ICS combination, LAMA and LABA) in people with moderate to severe COPD. The review will update previous systematic reviews on dual combination inhalers and long-acting bronchodilators to answer the questions described above using the strength of a network meta-analysis (NMA). SEARCH METHODS We identified studies from the Cochrane Airways Specialised Register, which contains several databases. We also conducted a search of ClinicalTrials.gov and manufacturers' websites. The most recent searches were conducted on 6 April 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs) that recruited people aged 35 years or older with a diagnosis of COPD and a baseline forced expiratory volume in one second (FEV1) of less than 80% of predicted. We included studies of at least 12 weeks' duration including at least two active comparators from one of the four inhaler groups. DATA COLLECTION AND ANALYSIS We conducted NMAs using a Bayesian Markov chain Monte Carlo method. We considered a study as high risk if recruited participants had at least one COPD exacerbation within the 12 months before study entry and as low risk otherwise. Primary outcomes were COPD exacerbations (moderate to severe and severe), and secondary outcomes included symptom and quality-of-life scores, safety outcomes, and lung function. We collected data only for active comparators and did not consider placebo was not considered. We assumed a class/group effect when a fixed-class model fitted well. Otherwise we used a random-class model to assess intraclass/group differences. We supplemented the NMAs with pairwise meta-analyses. MAIN RESULTS We included a total of 101,311 participants from 99 studies (26 studies with 32,265 participants in the high-risk population and 73 studies with 69,046 participants in the low-risk population) in our systematic review. The median duration of studies was 52 weeks in the high-risk population and 26 weeks in the low-risk population (range 12 to 156 for both populations). We considered the quality of included studies generally to be good.The NMAs suggested that the LABA/LAMA combination was the highest ranked treatment group to reduce COPD exacerbations followed by LAMA in the both populations.There is evidence that the LABA/LAMA combination decreases moderate to severe exacerbations compared to LABA/ICS combination, LAMA, and LABA in the high-risk population (network hazard ratios (HRs) 0.86 (95% credible interval (CrI) 0.76 to 0.99), 0.87 (95% CrI 0.78 to 0.99), and 0.70 (95% CrI 0.61 to 0.8) respectively), and that LAMA decreases moderate to severe exacerbations compared to LABA in the high- and low-risk populations (network HR 0.80 (95% CrI 0.71 to 0.88) and 0.87 (95% CrI 0.78 to 0.97), respectively). There is evidence that the LABA/LAMA combination reduces severe exacerbations compared to LABA/ICS combination and LABA in the high-risk population (network HR 0.78 (95% CrI 0.64 to 0.93) and 0.64 (95% CrI 0.51 to 0.81), respectively).There was a general trend towards a greater improvement in symptom and quality-of-life scores with the combination therapies compared to monotherapies, and the combination therapies were generally ranked higher than monotherapies.The LABA/ICS combination was the lowest ranked in pneumonia serious adverse events (SAEs) in both populations. There is evidence that the LABA/ICS combination increases the odds of pneumonia compared to LAMA/LABA combination, LAMA and LABA (network ORs: 1.69 (95% CrI 1.20 to 2.44), 1.78 (95% CrI 1.33 to 2.39), and 1.50 (95% CrI 1.17 to 1.92) in the high-risk population and network or pairwise OR: 2.33 (95% CI 1.03 to 5.26), 2.02 (95% CrI 1.16 to 3.72), and 1.93 (95% CrI 1.29 to 3.22) in the low-risk population respectively). There were significant overlaps in the rank statistics in the other safety outcomes including mortality, total, COPD, and cardiac SAEs, and dropouts due to adverse events.None of the differences in lung function met a minimal clinically important difference criterion except for LABA/LAMA combination versus LABA in the high-risk population (network mean difference 0.13 L (95% CrI 0.10 to 0.15). The results of pairwise meta-analyses generally agreed with those of the NMAs. There is no evidence to suggest intraclass/group differences except for lung function at 12 months in the high-risk population. AUTHORS' CONCLUSIONS The LABA/LAMA combination was the highest ranked treatment group to reduce COPD exacerbations although there was some uncertainty in the results. LAMA containing inhalers may have an advantage over those without a LAMA for preventing COPD exacerbations based on the rank statistics. Combination therapies appear more effective than monotherapies for improving symptom and quality-of-life scores. ICS-containing inhalers are associated with an increased risk of pneumonia.Our most comprehensive review including intraclass/group comparisons, free combination therapies, 99 studies, and 20 outcomes for each high- and low-risk population summarises the current literature and could help with updating existing COPD guidelines.
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Affiliation(s)
- Yuji Oba
- University of MissouriDivision of Pulmonary and Critical Care MedicineColumbiaMOUSA
| | - Edna Keeney
- University of BristolPopulation Health Sciences, Bristol Medical SchoolBristolUK
| | - Namratta Ghatehorde
- University of MissouriDivision of Pulmonary and Critical Care MedicineColumbiaMOUSA
| | - Sofia Dias
- University of YorkCentre for Reviews and DisseminationHeslingtonYorkUKYO10 5DD
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Izquierdo JL, Cosio BG. The dose of inhaled corticosteroids in patients with COPD: when less is better. Int J Chron Obstruct Pulmon Dis 2018; 13:3539-3547. [PMID: 30498343 PMCID: PMC6207269 DOI: 10.2147/copd.s175047] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The use of inhaled corticosteroids (ICS) in combination with bronchodilators in patients with COPD has been shown to decrease the rate of disease exacerbations and to improve the lung function and patients’ quality of life. However, their use has also been associated with an increased risk of pneumonia. Materials and methods We have reviewed existing clinical evidence on the risks and benefits of ICS in COPD, including large randomized clinical trials, meta-analyses, and clinical reviews. Results A large body of evidence supports the clinical benefits of ICS in patients with COPD in terms of exacerbations, symptoms, lung function, and quality of life. The incidence of adverse events related to ICS, including pneumonia, varies strongly among the studies and seems to be dose dependent, with recent well-designed, large studies on low-dose ICS reporting similar safety profiles in ICS and non-ICS groups. Conclusion The benefits of ICS in COPD continue to outweigh the risks, especially when lower ICS doses are employed. Given that the data on ICS withdrawal in COPD are scarce and conflicting, we argue that using reduced doses of ICS could be an optimal strategy to manage patients with COPD.
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Affiliation(s)
- José Luis Izquierdo
- Department of Pneumology and Medicine, Hospital Universitario, Universidad de Alcalá, Guadalajara, Spain,
| | - Borja G Cosio
- Department of Respiratory Medicine, Hospital Son Espases-IdISBa, Palma de Mallorca, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Stolz D, Hirsch HH, Schilter D, Louis R, Rakic J, Boeck L, Papakonstantinou E, Schindler C, Grize L, Tamm M. Reply to Palmer et al.: Does Dose Matter? Am J Respir Crit Care Med 2018; 198:1103-1105. [DOI: 10.1164/rccm.201806-1065le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Christian Schindler
- University of BaselBasel, Switzerland
- Swiss Tropical and Public Health InstituteBasel, Switzerland
| | - Leticia Grize
- University of BaselBasel, Switzerland
- Swiss Tropical and Public Health InstituteBasel, Switzerland
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Tashkin DP, Miravitlles M, Celli BR, Metzdorf N, Mueller A, Halpin DMG, Anzueto A. Concomitant inhaled corticosteroid use and the risk of pneumonia in COPD: a matched-subgroup post hoc analysis of the UPLIFT® trial. Respir Res 2018; 19:196. [PMID: 30290801 PMCID: PMC6173940 DOI: 10.1186/s12931-018-0874-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/27/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Use of inhaled corticosteroids (ICS) increases the risk of pneumonia in chronic obstructive pulmonary disease (COPD), but the magnitude of risk with different ICS remains unclear. METHODS A post hoc analysis of the 4-year UPLIFT® trial to assess whether pneumonia risk differed by type of ICS (fluticasone propionate [FP], other ICS, or no ICS) in permanent users (defined by use until end of study) or in users at baseline (sensitivity analysis). RESULTS For the permanent-users analysis, 825 patients receiving FP throughout the trial, 825 patients receiving other ICS and 825 patients not receiving ICS were matched on relevant baseline features 1:1:1. A significantly greater risk of pneumonia was observed for FP versus no ICS: the hazard ratio (HR) for risk of pneumonia was 1.33 (95% confidence interval [CI] 1.00, 1.75; p = 0.046) and the rate ratio (RR) was 1.58 (95% CI 1.05, 2.37; p = 0.028). A greater risk was also found for FP versus other ICS: HR 1.28 (95% CI 0.97, 1.68; p = 0.078) and RR 1.48 (95% CI 1.00, 2.19; p = 0.049). A higher proportion of patients on FP were hospitalized with pneumonia (7.9%) versus other ICS (6.7%) or no ICS (5.9%). Whilst other ICS use was associated with the highest number of fatal pneumonia events, the total number of fatal pneumonia incidents was low. A similar pattern was observed in the sensitivity analyses, which included 4002 patients on different treatments at baseline (FP, other ICS, and no ICS) and considered potential switches during the study. CONCLUSION The results support existing evidence of an increased pneumonia risk with FP use compared with other ICS and no ICS use in patients with COPD. Healthcare professionals should evaluate the risk-benefit ratio of using ICS when making treatment decisions with their patients. TRIAL REGISTRATION Post hoc analysis of UPLIFT®. ClinicalTrials.gov number: NCT00144339 . Retrospectively registered September 2, 2005.
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Affiliation(s)
- Donald P. Tashkin
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095-1690 USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | - Norbert Metzdorf
- TA Respiratory/Biosimilars, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Achim Mueller
- Biostatistics and Data Sciences Europe, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | | | - Antonio Anzueto
- Pulmonary/Critical Care, University of Texas, and South Texas Veterans Health Care System, San Antonio, TX USA
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45
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Liapikou A, Cilloniz C, Torres A. Drugs that increase the risk of community-acquired pneumonia: a narrative review. Expert Opin Drug Saf 2018; 17:991-1003. [PMID: 30196729 DOI: 10.1080/14740338.2018.1519545] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP), a major cause of morbidity and mortality, is the leading infectious cause of death in the developed world. Population-based studies and systematic reviews have identified a large number of risk factors for the development of pneumonia in adults. In addition to age, lifestyle habits, and comorbidities, some forms of pharmacotherapy may also increase the risk for CAP. AREAS COVERED MEDLINE, CENTRAL, and Web of Science were used in 2017 to search for case-control, cohort studies, as well as randomized controlled trials and meta-analysis that involved outpatient proton pump inhibitors (PPIs), inhaled corticosteroids (ICSs), antipsychotics, oral antidiabetics, and CAP diagnosis in patients aged >18 years. EXPERT OPINION Our review confirmed that the use of ICSs, PPIs or antipsychotic drugs was independently associated with an increased risk for CAP. We also identified a positive association between specific oral antidiabetics and the development of pneumonia.
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Affiliation(s)
- Adamantia Liapikou
- a 6th Respiratory Department , Sotiria Chest Diseases Hospital , Athens , Greece
| | - Catia Cilloniz
- b Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) , Barcelona , Spain
| | - Antoni Torres
- b Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) , Barcelona , Spain
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Ferguson GT, Papi A, Anzueto A, Kerwin EM, Cappelletti C, Duncan EA, Nyberg J, Dorinsky P. Budesonide/formoterol MDI with co-suspension delivery technology in COPD: the TELOS study. Eur Respir J 2018; 52:13993003.01334-2018. [PMID: 30220648 PMCID: PMC6383599 DOI: 10.1183/13993003.01334-2018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/12/2018] [Indexed: 11/09/2022]
Abstract
TELOS compared budesonide (BD)/formoterol fumarate dihydrate (FF) metered dose inhaler (BFF MDI), formulated using innovative co-suspension delivery technology that enables consistent aerosol performance, with its monocomponents and budesonide/formoterol fumarate dihydrate dry powder inhaler (DPI) in patients with moderate to very severe chronic obstructive pulmonary disease (COPD), without a requirement for an exacerbation history. In this phase III, double-blind, parallel-group, 24-week study (NCT02766608), patients were randomised to BFF MDI 320/10 µg (n=664), BFF MDI 160/10 µg (n=649), FF MDI 10 µg (n=648), BD MDI 320 µg (n=209) or open-label budesonide/formoterol DPI 400/12 µg (n=219). Primary end-points were change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) and FEV1 area under the curve from 0–4 h (AUC0–4). Time to first and rate of moderate/severe exacerbations were assessed. BFF MDI 320/10 µg improved pre-dose trough FEV1versus FF MDI (least squares mean (LSM) 39 mL; p=0.0018), and BFF MDI 320/10 µg and 160/10 µg improved FEV1 AUC0–4versus BD MDI (LSM 173 mL and 157 mL, respectively; both p<0.0001) at week 24. BFF MDI 320/10 µg and 160/10 µg improved time to first and rate of moderate/severe exacerbations versus FF MDI. Treatments were well tolerated, with pneumonia incidence ranging from 0.5–1.4%. BFF MDI improved lung function versus monocomponents and exacerbations versus FF MDI in patients with moderate to very severe COPD. TELOS: co-suspension delivery technology budesonide/formoterol fumarate dihydrate in a metered dose inhaler improved lung function and time to first and rate of exacerbations versus monocomponents in patients with moderate to very severe COPDhttp://ow.ly/ffWo30lrJL6
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Affiliation(s)
- Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Alberto Papi
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonio Anzueto
- Pulmonary Medicine and Critical Care, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | | | - Jack Nyberg
- Pearl - a member of the AstraZeneca Group, Morristown, NJ, USA
| | - Paul Dorinsky
- Pearl - a member of the AstraZeneca Group, Durham, NC, USA
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47
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Janson C, Johansson G, Ställberg B, Lisspers K, Olsson P, Keininger DL, Uhde M, Gutzwiller FS, Jörgensen L, Larsson K. Identifying the associated risks of pneumonia in COPD patients: ARCTIC an observational study. Respir Res 2018; 19:172. [PMID: 30200965 PMCID: PMC6131919 DOI: 10.1186/s12931-018-0868-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/20/2018] [Indexed: 12/27/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). Other factors such as severity of airflow limitation and concurrent asthma may further raise the possibility of developing pneumonia. This study assessed the risk of pneumonia associated with ICS in patients with COPD. Methods Electronic Medical Record data linked to National Health Registries were collected from COPD patients and matched reference controls in 52 Swedish primary care centers (2000–2014). Levels of ICS treatment (high, low, no ICS) and associated comorbidities were assessed. Patients were categorized by airflow limitation severity. Results A total of 6623 patients with COPD and 48,566 controls were analyzed. Patients with COPD had a more than 4-fold increase in pneumonia versus reference controls (hazard ratio [HR] 4.76, 95% confidence interval [CI]: 4.48–5.06). ICS use increased the risk of pneumonia by 20–30% in patients with COPD with forced expiratory volume in 1 s ≥ 50% versus patients not using ICS. Asthma was an independent risk factor for pneumonia in the COPD population. Multivariate analysis identified independent predictors of pneumonia in the overall population. The highest risk of pneumonia was associated with high dose ICS (HR 1.41, 95% CI: 1.23–1.62). Conclusions Patients with COPD have a greater risk of pneumonia versus reference controls; ICS use and concurrent asthma increased the risk of pneumonia further.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset, 75185, Uppsala, Sweden.
| | - Gunnar Johansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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Cheng SL. Blood eosinophils and inhaled corticosteroids in patients with COPD: systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2018; 13:2775-2784. [PMID: 30233168 PMCID: PMC6132232 DOI: 10.2147/copd.s175017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background COPD is a highly heterogeneous disease. Potential biomarkers to identify patients with COPD who will derive the greatest benefit from inhaled corticosteroid (ICS) treatment are needed. Blood eosinophil count can serve as a predictive biomarker for the efficacy of ICS treatment. The aim of this systematic review and meta-analysis was to assess whether a blood eosinophil count of ≥2% in patients undergoing ICS therapy was associated with a greater reduction in COPD exacerbation rate and pneumonia incidence. Materials and methods An electronic search was performed using the keywords "COPD", "eosinophil", and "clinical trial" in the PubMed and EMBASE databases to retrieve articles, up to 2017, relevant to our focus. Data were extracted, and a meta-analysis was conducted using RevMan 5 (version 5.3.5). Results Five studies comprising 12,496 patients with moderate-to-very severe COPD were included. At baseline, 60% of the patients had ≥2% blood eosinophils. Our meta-analysis showed a 17% reduction in exacerbation of moderate/severe COPD in patients with ≥2% blood eosinophils undergoing ICS therapy compared to the non-ICS/ICS withdrawal/placebo group. The difference between the two types of treatment was significant (risk ratio [RR], 0.816; 95% CI, 0.67-0.99; P=0.03). Furthermore, the risk of pneumonia-related events was significantly increased in the subgroup with eosinophil count ≥2% undergoing ICS-containing treatments (RR, 1.969; 95% CI, 1.369-2.833; P<0.001). There was no significant difference in the subgroup with eosinophil count <2% (RR, 1.29; 95% CI, 0.888-1.879; P<0.181). Conclusion The results of our meta-analysis suggest that the 2% threshold for blood eosinophils could accurately predict ICS treatment response in patients with COPD, but increased the risk of pneumonia.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan, .,Department of Chemical Engineering and Materials Science, Yuan-Ze University, Taoyuan, Taiwan,
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Gillen M, Forte P, Svensson JO, Lamarca R, Burke J, Rask K, Larsdotter Nilsson U, Eckerwall G. Effect of a spacer on total systemic and lung bioavailability in healthy volunteers and in vitro performance of the Symbicort ® (budesonide/formoterol) pressurized metered dose inhaler. Pulm Pharmacol Ther 2018; 52:7-17. [PMID: 30077809 DOI: 10.1016/j.pupt.2018.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 07/16/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Many patients with chronic obstructive pulmonary disease or asthma experience difficulties in coordinating inhalation with pressurized metered-dose inhaler (pMDI) actuation. The use of a spacer device can improve drug delivery in these patients. The aim of this study was to establish the relative bioavailability of single doses of Symbicort® (budesonide/formoterol) pMDI 160/4.5 μg/actuation (2 actuations) used with and without a spacer device. In addition, an in vitro study was conducted to characterize performance of the inhaler when used in conjunction with a spacer device. METHODS A Phase I, randomized, open-label, single-dose, single-center, crossover study in 50 healthy volunteers (NCT02934607) assessed the relative bioavailability of single-dose Symbicort® pMDI 160/4.5 μg/actuation (2 actuations) with and without a spacer (AeroChamber Plus® Flow-Vu®). Inhaled doses were administered without or with activated charcoal (taken orally) to estimate total systemic exposure and exposure through the lung, respectively. The in vitro study characterized the effect of the spacer with respect to delivered dose, fine particle dose, and dose during simulated breathing of budesonide and formoterol. RESULTS In terms of total systemic exposure, use of the spacer increased the relative bioavailability determined by AUC(0-last) and Cmax by 68% (spacer:no spacer treatment ratio, 167.9%; 90% CI, 144.1 to 195.6) and 99% (ratio, 198.7%; 90% CI, 164.4 to 240.2) for budesonide, and 77% (ratio, 176.6%; 90% CI, 145.1 to 215.0) and 124% (ratio, 223.6%; 90% CI, 189.9 to 263.3) for formoterol, respectively, compared with pMDI alone. Similarly, the lung exposure of budesonide and formoterol increased (AUC(0-last) and Cmax by 146% [ratio, 246.0%; 90% CI, 200.7 to 301.6] and 127% [ratio, 226.5%; 90% CI, 186.4 to 275.4] for budesonide, and 173% [ratio, 272.8%; 90% CI, 202.5 to 367.4] and 136% [ratio, 236.2%; 90% CI, 192.6 to 289.6] for formoterol, respectively) when the pMDI was administered through the spacer. When assessed by AUC(0-last) quartile without spacer, subjects in the lowest exposure quartile (indicating poor inhalation technique) with Symbicort® pMDI 160/4.5 μg/actuation (2 actuations) had markedly increased total systemic and lung exposure when the same dose was administered with the spacer. In contrast, for subjects in the highest exposure quartile with pMDI alone, total systemic and lung exposure of formoterol and budesonide was similar with and without the spacer. In the in vitro study, the fine particle dose (<5 μm) of both budesonide and formoterol from the spacer at delay time (i.e. pause period after actuation) = 0 s (instantaneous) after actuation was similar to the fine particle dose when not using the spacer. The delivered doses of budesonide and formoterol from the spacer were both lower compared with the doses administered without the spacer. There was also a decrease in delivered dose with increasing delay time. CONCLUSIONS The clinical study demonstrated that in subjects with poor inhalation technique the use of the AeroChamber Plus® Flow-Vu® spacer increased the bioavailability of Symbicort® pMDI to a level observed in subjects with good inhalation technique without a spacer. The findings from the in vitro study support the fine particle dose characteristics of Symbicort® pMDI with the AeroChamber Plus® Flow-Vu® spacer.
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Affiliation(s)
- Michael Gillen
- AstraZeneca - Quantitative Clinical Pharmacology, Gaithersburg, USA.
| | - Pablo Forte
- PAREXEL International Limited, PAREXEL Early Phase Clinical Unit, Level 7, Northwick Park Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, UK.
| | - Jan Olof Svensson
- AstraZeneca, Pepparedsleden 1, 431 50, Mölndal, Gothenburg, Sweden; Chalmers University of Technology, SE-412 96, Gothenburg, Sweden.
| | - Rosa Lamarca
- AstraZeneca, Avenida Diagonal, 615, 08028, Barcelona, Catalonia, Spain.
| | - Joanna Burke
- JB Stats Ltd, Reading, UK; AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK.
| | - Karolina Rask
- AstraZeneca, Pepparedsleden 1, 431 50, Mölndal, Gothenburg, Sweden.
| | | | - Göran Eckerwall
- AstraZeneca, Pepparedsleden 1, 431 50, Mölndal, Gothenburg, Sweden.
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Restrepo MI, Sibila O, Anzueto A. Pneumonia in Patients with Chronic Obstructive Pulmonary Disease. Tuberc Respir Dis (Seoul) 2018; 81:187-197. [PMID: 29962118 PMCID: PMC6030662 DOI: 10.4046/trd.2018.0030] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 11/24/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a frequent comorbid condition associated with increased morbidity and mortality. Pneumonia is the most common infectious disease condition. The purpose of this review is to evaluate the impact of pneumonia in patients with COPD. We will evaluate the epidemiology and factors associated with pneumonia. We are discussing the clinical characteristics of COPD that may favor the development of infections conditions such as pneumonia. Over the last 10 years, there is an increased evidence that COPD patients treated with inhaled corticosteroids are at increased risk to develp pneumonia. We will review the avaialbe information as well as the possible mechanism for this events. We also discuss the impact of influenza and pneumococcal vaccination in the prevention of pneumonia in COPD patients.
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Affiliation(s)
- Marcos I Restrepo
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT) (MR), San Antonio, TX, USA
| | - Oriol Sibila
- Servei de Pneumologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, TX, USA
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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