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Kricker JA, Page CP, Gardarsson FR, Baldursson O, Gudjonsson T, Parnham MJ. Nonantimicrobial Actions of Macrolides: Overview and Perspectives for Future Development. Pharmacol Rev 2021; 73:233-262. [PMID: 34716226 DOI: 10.1124/pharmrev.121.000300] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Macrolides are among the most widely prescribed broad spectrum antibacterials, particularly for respiratory infections. It is now recognized that these drugs, in particular azithromycin, also exert time-dependent immunomodulatory actions that contribute to their therapeutic benefit in both infectious and other chronic inflammatory diseases. Their increased chronic use in airway inflammation and, more recently, of azithromycin in COVID-19, however, has led to a rise in bacterial resistance. An additional crucial aspect of chronic airway inflammation, such as chronic obstructive pulmonary disease, as well as other inflammatory disorders, is the loss of epithelial barrier protection against pathogens and pollutants. In recent years, azithromycin has been shown with time to enhance the barrier properties of airway epithelial cells, an action that makes an important contribution to its therapeutic efficacy. In this article, we review the background and evidence for various immunomodulatory and time-dependent actions of macrolides on inflammatory processes and on the epithelium and highlight novel nonantibacterial macrolides that are being studied for immunomodulatory and barrier-strengthening properties to circumvent the risk of bacterial resistance that occurs with macrolide antibacterials. We also briefly review the clinical effects of macrolides in respiratory and other inflammatory diseases associated with epithelial injury and propose that the beneficial epithelial effects of nonantibacterial azithromycin derivatives in chronic inflammation, even given prophylactically, are likely to gain increasing attention in the future. SIGNIFICANCE STATEMENT: Based on its immunomodulatory properties and ability to enhance the protective role of the lung epithelium against pathogens, azithromycin has proven superior to other macrolides in treating chronic respiratory inflammation. A nonantibiotic azithromycin derivative is likely to offer prophylactic benefits against inflammation and epithelial damage of differing causes while preserving the use of macrolides as antibiotics.
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Affiliation(s)
- Jennifer A Kricker
- EpiEndo Pharmaceuticals, Reykjavik, Iceland (J.A.K., C.P.P., F.R.G., O.B., T.G., M.J.P.); Stem Cell Research Unit, Biomedical Center, University of Iceland, Reykjavik, Iceland (J.A.K., T.G.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); Department of Respiratory Medicine (O.B.), Department of Laboratory Hematology (T.G.), Landspitali-University Hospital, Reykjavik, Iceland; Faculty of Biochemistry, Chemistry and Pharmacy, JW Goethe University Frankfurt am Main, Germany (M.J.P.)
| | - Clive P Page
- EpiEndo Pharmaceuticals, Reykjavik, Iceland (J.A.K., C.P.P., F.R.G., O.B., T.G., M.J.P.); Stem Cell Research Unit, Biomedical Center, University of Iceland, Reykjavik, Iceland (J.A.K., T.G.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); Department of Respiratory Medicine (O.B.), Department of Laboratory Hematology (T.G.), Landspitali-University Hospital, Reykjavik, Iceland; Faculty of Biochemistry, Chemistry and Pharmacy, JW Goethe University Frankfurt am Main, Germany (M.J.P.)
| | - Fridrik Runar Gardarsson
- EpiEndo Pharmaceuticals, Reykjavik, Iceland (J.A.K., C.P.P., F.R.G., O.B., T.G., M.J.P.); Stem Cell Research Unit, Biomedical Center, University of Iceland, Reykjavik, Iceland (J.A.K., T.G.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); Department of Respiratory Medicine (O.B.), Department of Laboratory Hematology (T.G.), Landspitali-University Hospital, Reykjavik, Iceland; Faculty of Biochemistry, Chemistry and Pharmacy, JW Goethe University Frankfurt am Main, Germany (M.J.P.)
| | - Olafur Baldursson
- EpiEndo Pharmaceuticals, Reykjavik, Iceland (J.A.K., C.P.P., F.R.G., O.B., T.G., M.J.P.); Stem Cell Research Unit, Biomedical Center, University of Iceland, Reykjavik, Iceland (J.A.K., T.G.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); Department of Respiratory Medicine (O.B.), Department of Laboratory Hematology (T.G.), Landspitali-University Hospital, Reykjavik, Iceland; Faculty of Biochemistry, Chemistry and Pharmacy, JW Goethe University Frankfurt am Main, Germany (M.J.P.)
| | - Thorarinn Gudjonsson
- EpiEndo Pharmaceuticals, Reykjavik, Iceland (J.A.K., C.P.P., F.R.G., O.B., T.G., M.J.P.); Stem Cell Research Unit, Biomedical Center, University of Iceland, Reykjavik, Iceland (J.A.K., T.G.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); Department of Respiratory Medicine (O.B.), Department of Laboratory Hematology (T.G.), Landspitali-University Hospital, Reykjavik, Iceland; Faculty of Biochemistry, Chemistry and Pharmacy, JW Goethe University Frankfurt am Main, Germany (M.J.P.)
| | - Michael J Parnham
- EpiEndo Pharmaceuticals, Reykjavik, Iceland (J.A.K., C.P.P., F.R.G., O.B., T.G., M.J.P.); Stem Cell Research Unit, Biomedical Center, University of Iceland, Reykjavik, Iceland (J.A.K., T.G.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); Department of Respiratory Medicine (O.B.), Department of Laboratory Hematology (T.G.), Landspitali-University Hospital, Reykjavik, Iceland; Faculty of Biochemistry, Chemistry and Pharmacy, JW Goethe University Frankfurt am Main, Germany (M.J.P.)
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Cheng SL, Lin CH, Chu KA, Chiu KL, Lin SH, Lin HC, Ko HK, Chen YC, Chen CH, Sheu CC, Huang WC, Yang TM, Wei YF, Chien JY, Wang HC, Lin MC. Update on guidelines for the treatment of COPD in Taiwan using evidence and GRADE system-based recommendations. J Formos Med Assoc 2021; 120:1821-1844. [PMID: 34210585 DOI: 10.1016/j.jfma.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/14/2021] [Accepted: 06/11/2021] [Indexed: 12/20/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) has significant contributions to morbidity and mortality world-wide. Early symptoms of COPD are not readily distinguishable, resulting in a low rate of diagnosis and intervention. Different guidelines and recommendatations for the diagnosis and treatment of COPD exist globally. The first edition of clinical practice guidelines for COPD was published in 2016 by the Ministry of Health and Welfare in Taiwan in collaboration with the Taiwan evidence-based medicine association and Cochrane Taiwan, and was revised in 2019 in order to update recent diagnostic and therapeutic modalities for COPD and its acute exacerbation. This revised guideline covered a range of topics highlighted in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, including strategies for the diagnosis, assessment, monitoring, and management of stable COPD and exacerbations, with particular focus on evidence from Taiwan. The recommendations included in the revised guideline were formed based on a comprehensive systematic review or meta-analysis of specific clinical issues identified by an expert panel that surveyed relevant scientific evidence in the literature and guidelines published by the clinical communities and organizations nationally and internationally. The guidelines and recommendations are applicable to the clinical settings in Taiwan. We expect this revised guideline to facilitate the diagnosis, treatment and management of patients with COPD by physicians and health care professionals in Taiwan. Adaptations of the materials included herein for educational and training purposes is encouraged.
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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, Zhongli City, Taoyuan County, Taiwan
| | - Ching-Hsiung Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Kuo-An Chu
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuo-Liang Chiu
- Division of Chest Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; School of Post-baccalaureate Chinese Medicine, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Sheng-Hao Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Horng-Chyuan Lin
- Lin-Kou Medical Center of Chang Gung Memorial Hospital, Kwei-San, Tao-Yan, Taiwan
| | - Hsin-Kuo Ko
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Che Chen
- Kaohsiung Chang Gung MemoriaI Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Hung Chen
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chang Huang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsung-Ming Yang
- Division of Pulmonary and Critical Care Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yu-Feng Wei
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan; Division of Chest Medicine, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Meng-Chih Lin
- Kaohsiung Chang Gung MemoriaI Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Detailleur S, Vos R, Goeminne P. The Deteriorating Patient: Therapies Including Lung Transplantation. Semin Respir Crit Care Med 2021; 42:623-638. [PMID: 34261186 DOI: 10.1055/s-0041-1730946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.
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Affiliation(s)
- Stephanie Detailleur
- Department of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Pieter Goeminne
- Department of Respiratory Diseases, AZ Nikolaas, Sint-Niklaas, Belgium
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Ulmeanu R, Fildan AP, Rajnoveanu RM, Fira-Mladinescu O, Toma C, Nemes RM, Tudorache E, Oancea C, Mihaltan F. Romanian clinical guideline for diagnosis and treatment of COPD. J Int Med Res 2021; 48:300060520946907. [PMID: 32815452 PMCID: PMC7444126 DOI: 10.1177/0300060520946907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a disease with increasing prevalence and burden for health systems worldwide. Every country collects its own epidemiological data regarding COPD prevalence, morbidity and mortality while taking steps to educate the population and medical community to improve early detection and treatment. The rising COPD prevalence creates a need for comprehensive guidelines. In 2012 and 2017–2018, the Romanian Society of Pneumology (SRP) organised national inquiries for COPD, while lung physicians in Romania began receiving education regarding the correct algorithms for COPD diagnosis and therapy. During 2019, a Romanian clinical guideline for diagnosis and treatment of COPD was published, and a condensed version of key points from this guideline are presented herein. COPD is diagnosed based on the presence of three major components: relevant exposure history, respiratory symptoms, and airway limitation that is not fully reversible. Clinical evaluation of patients diagnosed with COPD should include the level of symptoms, exacerbation rate, the presence of comorbidities and determination of phenotypes. The present abridged guideline is designed to be accessible and practical for assessing and managing patients with COPD. The application of up-to-date COPD guidelines may enhance the optimism of physicians and patients in managing this disease.
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Affiliation(s)
- Ruxandra Ulmeanu
- Department of Pneumophysiology, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Ariadna Petronela Fildan
- Internal Medicine Discipline, Faculty of Medicine, Ovidius University of Constanţa, Constanţa, Romania
| | | | - Ovidiu Fira-Mladinescu
- Department of Pulmonology, Victor Babes University of Medicine and Pharmacy, Timişoara, Romania
| | - Claudia Toma
- Department of Pulmonology II, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Roxana Maria Nemes
- Preclinic Department, Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Emanuela Tudorache
- Department of Pulmonology, Victor Babes University of Medicine and Pharmacy, Timişoara, Romania
| | - Cristian Oancea
- Department of Pulmonology, Victor Babes University of Medicine and Pharmacy, Timişoara, Romania
| | - Florin Mihaltan
- Department of Pulmonology II, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Janjua S, Mathioudakis AG, Fortescue R, Walker RA, Sharif S, Threapleton CJ, Dias S. Prophylactic antibiotics for adults with chronic obstructive pulmonary disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 1:CD013198. [PMID: 33448349 PMCID: PMC8092479 DOI: 10.1002/14651858.cd013198.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by persistent respiratory symptoms and airflow limitation. Acute exacerbations punctuate the natural history of COPD and are associated with increased morbidity and mortality and disease progression. Chronic airflow limitation is caused by a combination of small airways (bronchitis) and parenchymal destruction (emphysema), which can impact day-to-day activities and overall quality of life. In carefully selected patients with COPD, long-term, prophylactic use of antibiotics may reduce bacterial load, inflammation of the airways, and the frequency of exacerbations. OBJECTIVES To assess effects of different prophylactic antibiotics on exacerbations, quality of life, and serious adverse events in people with COPD in three separate network meta-analyses (NMAs), and to provide rankings of identified antibiotics. SEARCH METHODS To identify eligible randomised controlled trials (RCTs), we searched the Cochrane Airways Group Specialised Register of trials and clinical trials registries. We conducted the most recent search on 22 January 2020. SELECTION CRITERIA We included RCTs with a parallel design of at least 12 weeks' duration evaluating long-term administration of antibiotics prophylactically compared with other antibiotics, or placebo, for patients with COPD. DATA COLLECTION AND ANALYSIS This Cochrane Review collected and updated pair-wise data from two previous Cochrane Reviews. Searches were updated and additional studies included. We conducted three separate network meta-analyses (NMAs) within a Bayesian framework to assess three outcomes: exacerbations, quality of life, and serious adverse events. For quality of life, we collected data from St George's Respiratory Questionnaire (SGRQ). Using previously validated methods, we selected the simplest model that could adequately fit the data for every analysis. We used threshold analysis to indicate which results were robust to potential biases, taking into account each study's contributions to the overall results and network structure. Probability ranking was performed for each antibiotic class for exacerbations, quality of life, and serious adverse events. MAIN RESULTS Characteristics of studies and participants Eight trials were conducted at multiple sites that included hospital clinics or academic health centres. Seven were single-centre trials conducted in hospital clinics. Two trials did not report settings. Trials durations ranged from 12 to 52 weeks. Most participants had moderate to severe disease. Mean age ranged from 64 years to 73 years, and more males were recruited (51% to 100%). Forced expiratory volume in one second (FEV₁) ranged from 0.935 to 1.36 L. Most participants had previous exacerbations. Data from 12 studies were included in the NMAs (3405 participants; 16 treatment arms including placebo). Prophylactic antibiotics evaluated were macrolides (azithromycin and erythromycin), tetracyclines (doxycyclines), quinolones (moxifloxacin) and macrolides plus tetracyclines (roxithromycin plus doxycycline). Risk of bias and threshold analysis Most studies were at low risk across domains, except detection bias, for which only seven studies were judged at low risk. In the threshold analysis for exacerbations, all comparisons in which one antibiotic was compared with another were robust to sampling variation, especially macrolide comparisons. Comparisons of classes with placebo were sensitive to potential bias, especially macrolide versus placebo, therefore, any bias in the comparison was likely to favour the active class, so any adjustment would bring the estimated relative effect closer to the null value, thus quinolone may become the best class to prevent exacerbations. Exacerbations Nine studies were included (2732 participants) in this NMA (exacerbations analysed as time to first exacerbation or people with one or more exacerbations). Macrolides and quinolones reduced exacerbations. Macrolides had a greater effect in reducing exacerbations compared with placebo (macrolides: hazard ratio (HR) 0.67, 95% credible interval (CrI) 0.60 to 0.75; quinolones: HR 0.89, 95% CrI 0.75 to 1.04), resulting in 127 fewer people per 1000 experiencing exacerbations on macrolides. The difference in exacerbations between tetracyclines and placebo was uncertain (HR 1.29, 95% CrI 0.66 to 2.41). Macrolides ranked first (95% CrI first to second), with quinolones ranked second (95% CrI second to third). Tetracyclines ranked fourth, which was lower than placebo (ranked third). Contributing studies were considered as low risk of bias in a threshold analysis. Quality of life (SGRQ) Seven studies were included (2237 participants) in this NMA. SGRQ scores improved with macrolide treatment compared with placebo (fixed effect-fixed class effect: mean difference (MD) -2.30, 95% CrI -3.61 to -0.99), but the mean difference did not reach the minimally clinical important difference (MCID) of 4 points. Tetracyclines and quinolones did not improve quality of life any more than placebo, and we did not detect a difference between antibiotic classes. Serious adverse events Nine studies were included (3180 participants) in the NMA. Macrolides reduced the odds of a serious adverse event compared with placebo (fixed effect-fixed class effect: odds ratio (OR) 0.76, 95% CrI 0.62 to 0.93). There was probably little to no difference in the effect of quinolone compared with placebo or tetracycline plus macrolide compared with placebo. There was probably little to no difference in serious adverse events between quinolones or tetracycline plus macrolide. With macrolide treatment 49 fewer people per 1000 experienced a serious adverse event compared with those given placebo. Macrolides ranked first, followed by quinolones. Tetracycline did not rank better than placebo. Drug resistance Ten studies reported drug resistance. Results were not combined due to variation in outcome measures. All studies concluded that prophylactic antibiotic administration was associated with the development of antimicrobial resistance. AUTHORS' CONCLUSIONS This NMA evaluated the safety and efficacy of different antibiotics used prophylactically for COPD patients. Compared to placebo, prolonged administration of macrolides (ranked first) appeared beneficial in prolonging the time to next exacerbation, improving quality of life, and reducing serious adverse events. No clear benefits were associated with use of quinolones or tetracyclines. In addition, antibiotic resistance was a concern and could not be thoroughly assessed in this review. Given the trade-off between effectiveness, safety, and risk of antibiotic resistance, prophylactic administration of antibiotics may be best reserved for selected patients, such as those experiencing frequent exacerbations. However, none of the eligible studies excluded patients with previously isolated non-tuberculous mycobacteria, which would contraindicate prophylactic administration of antibiotics, due to the risk of developing resistant non-tuberculous mycobacteria.
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Affiliation(s)
- Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University Foundation Trust, Manchester, UK
| | - Rebecca Fortescue
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Ruth Ae Walker
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sahar Sharif
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
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Wang C, Zhou J, Wang J, Li S, Fukunaga A, Yodoi J, Tian H. Progress in the mechanism and targeted drug therapy for COPD. Signal Transduct Target Ther 2020; 5:248. [PMID: 33110061 PMCID: PMC7588592 DOI: 10.1038/s41392-020-00345-x] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is emphysema and/or chronic bronchitis characterised by long-term breathing problems and poor airflow. The prevalence of COPD has increased over the last decade and the drugs most commonly used to treat it, such as glucocorticoids and bronchodilators, have significant therapeutic effects; however, they also cause side effects, including infection and immunosuppression. Here we reviewed the pathogenesis and progression of COPD and elaborated on the effects and mechanisms of newly developed molecular targeted COPD therapeutic drugs. Among these new drugs, we focussed on thioredoxin (Trx). Trx effectively prevents the progression of COPD by regulating redox status and protease/anti-protease balance, blocking the NF-κB and MAPK signalling pathways, suppressing the activation and migration of inflammatory cells and the production of cytokines, inhibiting the synthesis and the activation of adhesion factors and growth factors, and controlling the cAMP-PKA and PI3K/Akt signalling pathways. The mechanism by which Trx affects COPD is different from glucocorticoid-based mechanisms which regulate the inflammatory reaction in association with suppressing immune responses. In addition, Trx also improves the insensitivity of COPD to steroids by inhibiting the production and internalisation of macrophage migration inhibitory factor (MIF). Taken together, these findings suggest that Trx may be the ideal drug for treating COPD.
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Affiliation(s)
- Cuixue Wang
- Department of Basic Medicine, Medical College, Shaoxing University, Shaoxing, 312000, China
| | - Jiedong Zhou
- Department of Basic Medicine, Medical College, Shaoxing University, Shaoxing, 312000, China
| | - Jinquan Wang
- Department of Basic Medicine, Medical College, Shaoxing University, Shaoxing, 312000, China
| | - Shujing Li
- Department of Basic Medicine, Medical College, Shaoxing University, Shaoxing, 312000, China
| | - Atsushi Fukunaga
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Junji Yodoi
- Laboratory of Infection and Prevention, Department of Biological Response, Institute for Virus Research, Kyoto University, Kyoto, 606-8501, Japan
| | - Hai Tian
- Department of Basic Medicine, Medical College, Shaoxing University, Shaoxing, 312000, China.
- Jiaozhimei Biotechnology (Shaoxing) Co, Ltd, Shaoxing, 312000, China.
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7
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Smith D, Du Rand I, Addy CL, Collyns T, Hart SP, Mitchelmore PJ, Rahman NM, Saggu R. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax 2020; 75:370-404. [PMID: 32303621 DOI: 10.1136/thoraxjnl-2019-213929] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- David Smith
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
| | | | - Charlotte Louise Addy
- Centre for Medical Education, Queens University Belfast, Regional Respiratory Centre, Belfast City Hospital, Belfast, UK
| | - Timothy Collyns
- Medical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon Paul Hart
- Cardiovascular and Respiratory Studies, Hull York Medical School/University of Hull, Hull, UK
| | - Philip J Mitchelmore
- Institute of Biomedical and Clinical Science, College of Medicine & Health, University of Exeter, Exeter, UK.,Department of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit and Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Ravijyot Saggu
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
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8
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Gupta A, Ökesli-Armlovich A, Morgens D, Bassik MC, Khosla C. A genome-wide analysis of targets of macrolide antibiotics in mammalian cells. J Biol Chem 2020; 295:2057-2067. [PMID: 31915244 DOI: 10.1074/jbc.ra119.010770] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/05/2020] [Indexed: 01/04/2023] Open
Abstract
Macrolide antibiotics, such as erythromycin and josamycin, are natural polyketide products harboring 14- to 16-membered macrocyclic lactone rings to which various sugars are attached. These antibiotics are used extensively in the clinic because of their ability to inhibit bacterial protein synthesis. More recently, some macrolides have been shown to also possess anti-inflammatory and other therapeutic activities in mammalian cells. To better understand the targets and effects of this drug class in mammalian cells, we used a genome-wide shRNA screen in K562 cancer cells to identify genes that modulate cellular sensitivity to josamycin. Among the most sensitizing hits were proteins involved in mitochondrial translation and the mitochondrial unfolded protein response, glycolysis, and the mitogen-activated protein kinase signaling cascade. Further analysis revealed that cells treated with josamycin or other antibacterial agents exhibited impaired oxidative phosphorylation and metabolic shifts to glycolysis. Interestingly, we observed that knockdown of the mitogen-activated protein kinase kinase kinase 4 (MAP3K4) gene, which contributes to p38 mitogen-activated protein kinase signaling, sensitized cells only to josamycin but not to other antibacterial agents. There is a growing interest in better characterizing the therapeutic effects and toxicities of antibiotics in mammalian cells to guide new applications in both cellular and clinical studies. To our knowledge, this is the first report of an unbiased genome-wide screen to investigate the effects of a clinically used antibiotic on human cells.
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Affiliation(s)
- Amita Gupta
- Department of Chemical Engineering, Stanford University, Stanford, California 94305; Stanford Chemistry, Engineering and Medicine for Human Health (ChEM-H), Stanford University, Stanford, California 94305
| | - Aye Ökesli-Armlovich
- Stanford Chemistry, Engineering and Medicine for Human Health (ChEM-H), Stanford University, Stanford, California 94305; Department of Chemistry, Stanford University, Stanford, California 94305
| | - David Morgens
- Department of Genetics, Stanford University, Stanford, California 94305
| | - Michael C Bassik
- Stanford Chemistry, Engineering and Medicine for Human Health (ChEM-H), Stanford University, Stanford, California 94305; Department of Genetics, Stanford University, Stanford, California 94305
| | - Chaitan Khosla
- Department of Chemical Engineering, Stanford University, Stanford, California 94305; Stanford Chemistry, Engineering and Medicine for Human Health (ChEM-H), Stanford University, Stanford, California 94305; Department of Chemistry, Stanford University, Stanford, California 94305; Department of Biochemistry, Stanford University, Stanford, California 94305.
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9
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Wang Y, Zijp TR, Bahar MA, Kocks JWH, Wilffert B, Hak E. Effects of prophylactic antibiotics on patients with stable COPD: a systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2019; 73:3231-3243. [PMID: 30189002 DOI: 10.1093/jac/dky326] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/17/2018] [Indexed: 11/14/2022] Open
Abstract
Background As bacterial infections provoke exacerbations, COPD patients may benefit from prophylactic antibiotics. However, evidence regarding their overall benefit-risk profile is conflicting. Objectives To update previous evidence and systematically evaluate the beneficial effects and side effects of prophylactic antibiotics in stable COPD patients. Methods Several databases were searched up to 26 April 2017 for randomized controlled trials (RCTs) on prophylactic antibiotics in stable COPD patients. The primary outcomes were exacerbations and quality of life. Duration and schedule of antibiotics were considered in subgroup analyses. Results Twelve RCTs involving 3683 patients were included. Prophylactic antibiotics significantly reduced the frequency of exacerbations [risk ratio (RR) 0.74, 95% CI 0.60-0.92] and the number of patients with one or more exacerbations (RR 0.82, 95% CI 0.74-0.90). Erythromycin and azithromycin appeared the most effective, with the number needed to treat ranging from four to seven. Quality of life was also significantly improved by prophylactic antibiotics (mean difference -1.55, 95% CI -2.59 to -0.51). Time to first exacerbation was prolonged in six studies, with one conflicting result. Neither the rate of hospitalization nor the rate of adverse events was significantly changed. Furthermore, no significant changes were observed in lung function, bacterial load and airway inflammation. However, antibiotic-resistant isolates were significantly increased (OR 4.49, 95% CI 2.48-8.12). Conclusions Prophylactic antibiotics were effective in preventing COPD exacerbations and improving quality of life among stable patients with moderate to severe COPD. The choice of prophylactic antibiotics should be analysed and considered case by case, especially for long and continuous use.
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Affiliation(s)
- Yuanyuan Wang
- Department of PharmacoTherapy -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Tanja R Zijp
- Department of PharmacoTherapy -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Muh Akbar Bahar
- Department of PharmacoTherapy -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands.,Faculty of Pharmacy, Hasanuddin University, Makassar, Indonesia
| | - Janwillem W H Kocks
- Department of General Practice and Elderly Care Medicine, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bob Wilffert
- Department of PharmacoTherapy -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eelko Hak
- Department of PharmacoTherapy -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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10
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Wang X, Luo J, Wang D, Liu B, Liu C. The efficacy and safety of long-term add-on treatment of azithromycin in asthma: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e17190. [PMID: 31567962 PMCID: PMC6756741 DOI: 10.1097/md.0000000000017190] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM Effects of azithromycin on asthma reported in clinical trials are less consistent. We aimed to further clarify the efficacy and safety of azithromycin in treatment of asthma. METHODS The protocol registration number was CRD42017074318 (http://www.crd.york.ac.uk/Prospero). We searched PubMed, EMBASE, Cochrane databases, China National Knowledge Internet (CNKI), and Wanfang databases for the randomized controlled trials (RCTs) with prolonged treatment of azithromycin for more than 3 weeks. Random-effects or fixed-effects model was applied to calculate risk ratio (RR) and mean difference (MD) for dichotomous and continuous data respectively. RESULTS A total of eight studies were included for analysis. The pooled result of adjunctive azithromycin therapy in asthma showed a small, but statistically significant increase in forced expiratory volume in one second (FEV1) (MD = 0.06, 95% confidence interval [CI]: 0.01-0.12, P = .02), but no significant differences in exacerbation frequency (MD = -0.42, 95%CI: -1.13 to 0.30, P = .25) and peak expiratory flow (PEF) (MD = 0.20, 95% CI: -0.05 to 0.44, P = .12), fractional exhaled nitric oxide (FeNO) (MD = 4.12, 95% CI: -2.06 to 10.30, P = .19), asthma quality of life questionnaire (AQLQ) (MD: 0.05, 95% CI: -0.17 to 0.28, P = .65), asthma control questionnaire (ACQ) (MD: -0.03, 95% CI: -0.21 to 0.15, P = .75). The subgroup analysis revealed that azithromycin could decrease FeNO among Asian asthma (MD = 15.04, 95% CI: 6.18-23.90, P = .0009). CONCLUSIONS Add-on therapy of azithromycin in asthma patients could improve the FEV1, but failed to improve asthma exacerbations, PEF, ACQ, AQLQ, and FeNO. Subgroup analysis indicated that azithromycin could improve FeNO in Asian group asthmatics.
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11
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Cao Y, Xuan S, Wu Y, Yao X. Effects of long-term macrolide therapy at low doses in stable COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:1289-1298. [PMID: 31354258 PMCID: PMC6572718 DOI: 10.2147/copd.s205075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/30/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is currently the fourth largest fatal disease in the world, and is expected to rise to third place by 2020. Frequent acute exacerbations lead to increased mortality. Some suggestions for prophylactic use of macrolides in preventing COPD exacerbations have been raised, but there are still several issues that need to be addressed, such as target population, the course of treatment, therapeutic dose, and so on. Objective: To evaluate, via exploratory meta-analysis, the efficacy of long-term macrolide therapy at low doses in stable COPD. Methods: A systematic literature search was performed in PubMed, Embase, and Cochrane database from inception to March 28, 2019. Randomized controlled trials (RCT) which reported long-term use of macrolides in prevention of COPD were eligible. Results: A total of 10 articles were included in this study. It was found that there was a 23% relative risk reduction in COPD exacerbations among patients taking macrolides compared to placebo (P<0.01). The median time to first exacerbation was effectively prolonged among patients taking macrolides vs placebo (P<0.01). Sub-group analysis showed erythromycin was advantageous and older patients were less responsive to macrolides. Conclusions: Long-term low dose usage of macrolides could significantly reduce the frequency of the acute exacerbation of COPD. The treatment was well tolerated, with few adverse reactions, but it was not suitable for the elderly. It is recommended that this treatment regimen could be used in patients with GOLD grading C or D, because they have a higher risk of acute exacerbation and mortality. It needs to be further discussed whether this treatment should last for 12 months or longer.
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Affiliation(s)
- Yueqin Cao
- Department of Pulmonary Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, People's Republic of China.,Department of Pulmonary Medicine, The Fouth People's Hospital of Taizhou, Taizhou, Jiangsu Province 225300, People's Republic of China
| | - Shurui Xuan
- Department of Pulmonary Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, People's Republic of China
| | - Yunhui Wu
- Department of Pulmonary Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, People's Republic of China
| | - Xin Yao
- Department of Pulmonary Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, People's Republic of China
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12
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Threapleton CJD, Janjua S, Fortescue R, Baker EH. Head-to-head oral prophylactic antibiotic therapy for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2019; 5:CD013024. [PMID: 31125127 PMCID: PMC6534184 DOI: 10.1002/14651858.cd013024.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD; including chronic bronchitis and emphysema) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. Long-term antibiotic use may reduce both bacterial load and inflammation in the airways. Studies have shown a reduction of exacerbations with antibiotics in comparison to placebo in people with COPD, but there are concerns about antibiotic resistance and safety. OBJECTIVES To compare the safety and efficacy of different classes of antibiotics (continuous, intermittent or pulsed) for prophylaxis of exacerbations in patients with COPD. SEARCH METHODS We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was conducted on 6 February 2019. SELECTION CRITERIA Randomised controlled trials (RCTs) were selected that compared one prophylactic antibiotic with another in patients with COPD. DATA COLLECTION AND ANALYSIS We used the standard Cochrane methods. Two independent review authors selected trials for inclusion, extracted data and assessed risk of bias. Discrepancies were resolved by involving a third review author. MAIN RESULTS We included two RCTs, both published in 2015 involving a total of 391 participants with treatment duration of 12 to 13 weeks. One RCT compared a quinolone (moxifloxacin pulsed, for 5 days every 4 weeks), with a tetracycline (doxycycline continuous) or a macrolide (azithromycin intermittent).The second RCT compared a tetracycline (doxycycline continuous) plus a macrolide (roxithromycin continuous), with roxithromycin (continuous) alone.The trials recruited participants with a mean age of 68 years, with moderate-severity COPD. Both trials included participants who had between two and five exacerbations in the previous one to two years. In one trial, 17% of patients had previously been using inhaled corticosteroids. In the other study, all patients were positive for Chlamydophila pneumoniae (C pneumoniae).Overall, we judged the evidence presented to be of very low-certainty, mainly due to imprecision, but we also had concerns about indirectness and methodological quality of the included studies. The primary outcome measures for this review included exacerbations, quality of life, drug resistance and serious adverse events.Macrolide + tetracycline versus macrolide There was no clear difference between treatments in improvement in quality of life as assessed by the Chronic Respiratory Questionnaire (CRQ). The CRQ scale ranges from 0 to 10 and higher scores on the scale indicate better quality of life. CRQ sub-scales for dyspnoea (mean difference (MD) 0.58, 95% confidence interval (CI) -0.84 to 2.00; 187 participants; very low-certainty evidence), fatigue (MD 0.02, 95% CI -1.08 to 1.12; 187 participants; very low-certainty evidence), emotional function (MD -0.37, 95% CI -1.74 to 1.00; 187 participants; very low-certainty evidence), or mastery (MD -0.79, 95% CI -1.86 to 0.28; 187 participants; very low-certainty evidence) at 12 weeks. For serious adverse events, it was uncertain if there was a difference between combined roxithromycin and doxycycline versus roxithromycin alone at 48 weeks follow-up after active treatment of 12 weeks (odds ratio (OR) 1.00, 95% CI 0.52 to 1.93; 198 participants; very low-certainty evidence). There were five deaths reported in the combined treatment arm, versus three in the single treatment arm at 48 weeks follow-up after active treatment of 12 weeks (OR 1.63, 95% CI 0.38 to 7.02; 198 participants; very low-certainty evidence).Quinolone versus tetracycline There was no clear difference between moxifloxacin and doxycycline for the number of participants experiencing one or more exacerbations (OR 0.44, 95% CI 0.14 to 1.38; 50 participants, very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.Quinolone versus macrolide There was no clear difference between moxifloxacin and azithromycin for the number of participants experiencing one or more exacerbations (OR 1.00, 95% CI 0.32 to 3.10; 50 participants; very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.Marcolide versus tetracycline There was no clear difference between azithromycin and doxycycline for the number of participants experiencing one or more exacerbations (OR 0.44, 95% CI 0.14 to 1.38; 50 participants; very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.We did not find head-to-head evidence for impact of antibiotics on drug resistance. AUTHORS' CONCLUSIONS It is not clear from the evidence included in this review whether there is a difference in efficacy or safety between different classes or regimens of prophylactic antibiotic, given for 12 to 13 weeks to people with COPD. Whilst no head-to-head comparisons of antibiotic resistance were identified, concerns about this continue. The sample size in this review is small and both included studies are of short duration. Thus, there is considerable uncertainty in effects observed and the effects of different prophylactic antibiotics requires further research.
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Affiliation(s)
| | - Sadia Janjua
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Rebecca Fortescue
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Emma H Baker
- St George's, University of LondonClinical PharmacologyLondonUK
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Davidson RJ. In vitro activity and pharmacodynamic/pharmacokinetic parameters of clarithromycin and azithromycin: why they matter in the treatment of respiratory tract infections. Infect Drug Resist 2019; 12:585-596. [PMID: 30881064 PMCID: PMC6413744 DOI: 10.2147/idr.s187226] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Clarithromycin and azithromycin are second-generation macrolides established and widely used for treating a range of upper and lower respiratory tract infections. Extensive clinical trials data indicate that these drugs are highly effective in these applications and broadly comparable in their clinical and microbiological effectiveness. However, consideration of pharmacokinetic, metabolic, and tissue-penetration data, including the significant antibacterial activity of the metabolite 14-hydroxy-clarithromycin, plus the findings of pharmacodynamic modeling, provide evidence that the long half-life and lower potency of azithromycin predispose this agent to select for resistant isolates. Comparison of the "mutant-prevention concentrations" of clarithromycin and azithromycin, and examination of large-scale epidemiological data from Canada, also support the view that these drugs differ materially in their propensity to promote resistance among bacterial strains implicated in common respiratory infections, and that clarithromycin may offer important advantages over azithromycin that should be considered when choosing a macrolide to treat these conditions.
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Affiliation(s)
- Ross J Davidson
- Department of Pathology and Laboratory Medicine, Division of Microbiology, Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada,
- Department of Medicine,
- Department of Pathology,
- Department of Microbiology & Immunology, Dalhousie University, Halifax, NS, Canada,
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14
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Cui Y, Luo L, Li C, Chen P, Chen Y. Long-term macrolide treatment for the prevention of acute exacerbations in COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2018; 13:3813-3829. [PMID: 30538443 PMCID: PMC6254503 DOI: 10.2147/copd.s181246] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acute exacerbation of COPD (AECOPD) is associated with an increased hospitalization and mortality. Azithromycin and erythromycin are the recommended drugs to reduce the risk of exacerbations. However, the most suitable duration of therapy and drug-related adverse events are still a matter of debate. The aim of this meta-analysis was to assess the current evidence regarding the efficacy and safety of long-term macrolide treatment for COPD. Materials and methods We comprehensively searched PubMed, Embase, the Cochrane Library, and the Web of Science and performed a systematic review and cumulative meta-analysis of all randomized controlled trials (RCTs) and retrospective studies. Results Eleven RCTs and one retrospective study including a total of 2,151 cases were carried out. Long-term macrolide treatment significantly reduced the total number of cases with one or more exacerbations (OR=0.40; 95% CI=0.24–0.65; P<0.01) and the rate of exacerbations per patient per year (risk ratio [RR]=0.60; 95% CI=0.45–0.78; P<0.01). Subgroup analyses showed that the minimum duration for drug efficacy for both azithromycin and erythromycin therapy was 6 months. In addition, macrolide therapy could improve the St George Respiratory Questionnaire (SGRQ) total score (P<0.01) but did not achieve the level of clinical significance. The frequency of hospitalizations was not significantly different between the treatment and control groups (P=0.50). Moreover, chronic azithromycin treatment was more likely to increase adverse events (P<0.01). Conclusion Prophylactic azithromycin or erythromycin treatment has a significant effect in reducing the frequency of AECOPD in a time-dependent manner. However, long-term macrolide treatment could increase the occurrence of adverse events and macrolide resistance. Future large-scale, well-designed RCTs with extensive follow-up are required to identify patients in whom the benefits outweigh risks.
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Affiliation(s)
- Yanan Cui
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Lijuan Luo
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Chenbei Li
- Biomedical Clinical Medicine, The Queen Marry University of London of Nanchang University, Jiangxi, China
| | - Ping Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Yan Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
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15
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Vollenweider DJ, Frei A, Steurer‐Stey CA, Garcia‐Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2018; 10:CD010257. [PMID: 30371937 PMCID: PMC6517133 DOI: 10.1002/14651858.cd010257.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However, the value of antibiotics remains uncertain, as systematic reviews and clinical trials have shown conflicting results. OBJECTIVES To assess effects of antibiotics on treatment failure as observed between seven days and one month after treatment initiation (primary outcome) for management of acute COPD exacerbations, as well as their effects on other patient-important outcomes (mortality, adverse events, length of hospital stay, time to next exacerbation). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, MEDLINE, Embase, and other electronically available databases up to 26 September 2018. SELECTION CRITERIA We sought to find randomised controlled trials (RCTs) including people with acute COPD exacerbations comparing antibiotic therapy and placebo and providing follow-up of at least seven days. DATA COLLECTION AND ANALYSIS Two review authors independently screened references and extracted data from trial reports. We kept the three groups of outpatients, inpatients, and patients admitted to the intensive care unit (ICU) separate for benefit outcomes and mortality because we considered them to be clinically too different to be summarised as a single group. We considered outpatients to have a mild to moderate exacerbation, inpatients to have a severe exacerbation, and ICU patients to have a very severe exacerbation. When authors of primary studies did not report outcomes or study details, we contacted them to request missing data. We calculated pooled risk ratios (RRs) for treatment failure, Peto odds ratios (ORs) for rare events (mortality and adverse events), and mean differences (MDs) for continuous outcomes using random-effects models. We used GRADE to assess the quality of the evidence. The primary outcome was treatment failure as observed between seven days and one month after treatment initiation. MAIN RESULTS We included 19 trials with 2663 participants (11 with outpatients, seven with inpatients, and one with ICU patients).For outpatients (with mild to moderate exacerbations), evidence of low quality suggests that currently available antibiotics statistically significantly reduced the risk for treatment failure between seven days and one month after treatment initiation (RR 0.72, 95% confidence interval (CI) 0.56 to 0.94; I² = 31%; in absolute terms, reduction in treatment failures from 295 to 212 per 1000 treated participants, 95% CI 165 to 277). Studies providing older antibiotics not in use anymore yielded an RR of 0.69 (95% CI 0.53 to 0.90; I² = 31%). Evidence of low quality from one trial in outpatients suggested no effects of antibiotics on mortality (Peto OR 1.27, 95% CI 0.49 to 3.30). One trial reported no effects of antibiotics on re-exacerbations between two and six weeks after treatment initiation. Only one trial (N = 35) reported health-related quality of life but did not show a statistically significant difference between treatment and control groups.Evidence of moderate quality does not show that currently used antibiotics statistically significantly reduced the risk of treatment failure among inpatients with severe exacerbations (i.e. for inpatients excluding ICU patients) (RR 0.65, 95% CI 0.38 to 1.12; I² = 50%), but trial results remain uncertain. In turn, the effect was statistically significant when trials included older antibiotics no longer in clinical use (RR 0.76, 95% CI 0.58 to 1.00; I² = 39%). Evidence of moderate quality from two trials including inpatients shows no beneficial effects of antibiotics on mortality (Peto OR 2.48, 95% CI 0.94 to 6.55). Length of hospital stay (in days) was similar in antibiotic and placebo groups.The only trial with 93 patients admitted to the ICU showed a large and statistically significant effect on treatment failure (RR 0.19, 95% CI 0.08 to 0.45; moderate-quality evidence; in absolute terms, reduction in treatment failures from 565 to 107 per 1000 treated participants, 95% CI 45 to 254). Results of this trial show a statistically significant effect on mortality (Peto OR 0.21, 95% CI 0.06 to 0.72; moderate-quality evidence) and on length of hospital stay (MD -9.60 days, 95% CI -12.84 to -6.36; low-quality evidence).Evidence of moderate quality gathered from trials conducted in all settings shows no statistically significant effect on overall incidence of adverse events (Peto OR 1.20, 95% CI 0.89 to 1.63; moderate-quality evidence) nor on diarrhoea (Peto OR 1.68, 95% CI 0.92 to 3.07; moderate-quality evidence). AUTHORS' CONCLUSIONS Researchers have found that antibiotics have some effect on inpatients and outpatients, but these effects are small, and they are inconsistent for some outcomes (treatment failure) and absent for other outcomes (mortality, length of hospital stay). Analyses show a strong beneficial effect of antibiotics among ICU patients. Few data are available on the effects of antibiotics on health-related quality of life or on other patient-reported symptoms, and data show no statistically significant increase in the risk of adverse events with antibiotics compared to placebo. These inconsistent effects call for research into clinical signs and biomarkers that can help identify patients who would benefit from antibiotics, while sparing antibiotics for patients who are unlikely to experience benefit and for whom downsides of antibiotics (side effects, costs, and multi-resistance) should be avoided.
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Affiliation(s)
| | - Anja Frei
- University of ZurichEpidemiology, Biostatistics and Prevention InstituteZurichSwitzerland
| | - Claudia A Steurer‐Stey
- University of ZurichEpidemiology, Biostatistics and Prevention InstituteZurichSwitzerland
| | - Judith Garcia‐Aymerich
- ISGlobalBarcelonaSpain08003
- Universitat Pompeu Fabra (UPF)BarcelonaSpain
- CIBER Epidemiologia y Salud Publica (CIBERESP)BarcelonaSpain
| | - Milo A Puhan
- University of ZurichEpidemiology, Biostatistics and Prevention InstituteZurichSwitzerland
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16
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Polverino E, Dimakou K, Hurst J, Martinez-Garcia MA, Miravitlles M, Paggiaro P, Shteinberg M, Aliberti S, Chalmers JD. The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions. Eur Respir J 2018; 52:13993003.00328-2018. [PMID: 30049739 DOI: 10.1183/13993003.00328-2018] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/10/2018] [Indexed: 11/05/2022]
Abstract
Bronchiectasis is a clinical and radiological diagnosis associated with cough, sputum production and recurrent respiratory infections. The clinical presentation inevitably overlaps with other respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD). In addition, 4-72% of patients with severe COPD are found to have radiological bronchiectasis on computed tomography, with similar frequencies (20-30%) now being reported in cohorts with severe or uncontrolled asthma. Co-diagnosis of bronchiectasis with another airway disease is associated with increased lung inflammation, frequent exacerbations, worse lung function and higher mortality. In addition, many patients with all three disorders have chronic rhinosinusitis and upper airway disease, resulting in a complex "mixed airway" phenotype.The management of asthma, bronchiectasis, COPD and upper airway diseases has traditionally been outlined in separate guidelines for each individual disorder. Recognition that the majority of patients have one or more overlapping pathologies requires that we re-evaluate how we treat airway disease. The concept of treatable traits promotes a holistic, pathophysiology-based approach to treatment rather than a syndromic approach and may be more appropriate for patients with overlapping features.Here, we review the current clinical definition, diagnosis, management and future directions for the overlap between bronchiectasis and other airway diseases.
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Affiliation(s)
- Eva Polverino
- Pneumology Dept, Hospital Universitari Vall d'Hebron (HUVH), Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain.,CIBER, Spain
| | | | - John Hurst
- UCL Respiratory, University College London, London, UK
| | | | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron (HUVH), Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain.,CIBER, Spain
| | - Pierluigi Paggiaro
- Dept of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Italy
| | - Michal Shteinberg
- Pulmonology Institute and Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel.,Technion-Israel Institute of Technology, The B. Rappaport Faculty of Medicine, Haifa, Israel
| | - Stefano Aliberti
- Dept of Pathophysiology and Transplantation, University of Milan Internal Medicine Dept, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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17
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Feldman C, Richards G. Appropriate antibiotic management of bacterial lower respiratory tract infections. F1000Res 2018; 7:F1000 Faculty Rev-1121. [PMID: 30079235 PMCID: PMC6058472 DOI: 10.12688/f1000research.14226.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 01/05/2023] Open
Abstract
Lower respiratory tract infections are the leading cause of infectious disease deaths worldwide and are the fifth leading cause of death overall. This is despite conditions such as pneumococcal infections and influenza being largely preventable with the use of appropriate vaccines. The mainstay of treatment for the most important bacterial lower respiratory tract infections, namely acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP), is the use of antibiotics. Yet despite a number of recent publications, including clinical studies as well as several systematic literature reviews and meta-analyses, there is considerable ongoing controversy as to what the most appropriate antibiotics are for the empiric therapy of CAP in the different settings (outpatient, inpatient, and intensive care unit). Furthermore, in the case of AECOPD, there is a need for consideration of which of these exacerbations actually need antibiotic treatment. This article describes these issues and makes suggestions for appropriately managing these conditions, in the setting of the need for antimicrobial stewardship initiatives designed to slow current emerging rates of antibiotic resistance, while improving patient outcomes.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Guy Richards
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, and Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
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18
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Zimmermann P, Ziesenitz VC, Curtis N, Ritz N. The Immunomodulatory Effects of Macrolides-A Systematic Review of the Underlying Mechanisms. Front Immunol 2018; 9:302. [PMID: 29593707 PMCID: PMC5859047 DOI: 10.3389/fimmu.2018.00302] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background The mechanisms underlying the non-antimicrobial immunomodulatory properties of macrolides are not well understood. Objectives To systematically review the evidence for the immunomodulatory properties of macrolides in humans and to describe the underlying mechanism and extent of their influence on the innate and adaptive immune system. Methods A systematic literature search was done in MEDLINE using the OVID interface from 1946 to December 2016 according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA). Original articles investigating the influence of four macrolides (azithromycin, clarithromycin, erythromycin, and roxithromycin) on immunological markers in humans were included. Results We identified 22 randomized, controlled trials, 16 prospective cohort studies, and 8 case–control studies investigating 47 different immunological markers (186 measurements) in 1,834 participants. The most frequently reported outcomes were a decrease in the number of neutrophils, and the concentrations of neutrophil elastase, interleukin (IL)-8, IL-6, IL-1beta, tumor necrosis factor (TNF)-alpha, eosinophilic cationic protein, and matrix metalloproteinase 9. Inhibition of neutrophil function was reported more frequently than eosinophil function. A decrease in T helper (Th) 2 cells cytokines (IL-4, IL-5, IL-6) was reported more frequently than a decrease in Th1 cytokines (IL-2, INF-gamma). Conclusion Macrolides influence a broad range of immunological mechanisms resulting in immunomodulatory effects. To optimize the treatment of chronic inflammatory diseases by macrolides, further studies are necessary, particularly comparing different macrolides and dose effect relationships.
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Affiliation(s)
- Petra Zimmermann
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.,Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, VIC, Australia.,Infectious Diseases Unit, University of Basel Children's Hospital, Basel, Switzerland
| | - Victoria C Ziesenitz
- Paediatric Pharmacology, University of Basel Children's Hospital, Basel, Switzerland
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.,Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Nicole Ritz
- Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infectious Diseases Unit, University of Basel Children's Hospital, Basel, Switzerland.,Paediatric Pharmacology, University of Basel Children's Hospital, Basel, Switzerland
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Ballow M, Paris K, de la Morena M. Should Antibiotic Prophylaxis Be Routinely Used in Patients with Antibody-Mediated Primary Immunodeficiency? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:421-426. [DOI: 10.1016/j.jaip.2017.11.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/05/2017] [Accepted: 11/08/2017] [Indexed: 01/07/2023]
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Volgers C, Grauls GE, Hellebrand PHM, Savelkoul PHM, Stassen FRM. Budesonide, fluticasone propionate, and azithromycin do not modulate the membrane vesicle release by THP-1 macrophages and respiratory pathogens during macrophage infection. Inflammopharmacology 2017; 25:643-651. [PMID: 28528362 PMCID: PMC5671549 DOI: 10.1007/s10787-017-0359-7] [Citation(s) in RCA: 2] [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: 03/14/2017] [Accepted: 05/05/2017] [Indexed: 12/21/2022]
Abstract
Patients with more severe chronic obstructive pulmonary disease frequently experience exacerbations and it is estimated that up to 50% of these exacerbations are associated with bacterial infections. The mainstay treatment for these infection-related exacerbations constitutes the administration of glucocorticoids, alone or in combination with antibiotics. A recent line of evidence demonstrates that many hormones including the steroid beclomethasone can also directly affect bacterial growth, virulence, and antibiotic resistance. The effect of these regimens on the release of potentially virulent and toxic membrane vesicles (MVs) is at present unclear. In this study, we determined the effect of several pharmacological agents on MVs release by and bacterial growth of common respiratory pathogens. We found that neither the release of MVs nor the bacterial growth was affected by the glucocorticoids budesonide and fluticasone. The macrolide antibiotic azithromycin only inhibited the growth of Moraxella catarrhalis but no effects were observed on bacterial MV release at a concentration that is achieved locally in the epithelial lining on administration. The macrophage pro-inflammatory response to MVs was significantly reduced after treatment with budesonide and fluticasone but not by azithromycin treatment. Our findings suggest that these glucocorticoids may have a positive effect on infection-related inflammation although the bacterial growth and MV release remained unaffected.
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Affiliation(s)
- Charlotte Volgers
- Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HZ, Maastricht, The Netherlands
| | - Gert E Grauls
- Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HZ, Maastricht, The Netherlands
| | - Pauline H M Hellebrand
- Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HZ, Maastricht, The Netherlands
| | - Paul H M Savelkoul
- Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HZ, Maastricht, The Netherlands
- Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
| | - Frank R M Stassen
- Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HZ, Maastricht, The Netherlands.
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Messinger-Rapport BJ, Little MO, Morley JE, Gammack JK. Clinical Update on Nursing Home Medicine: 2017. J Am Med Dir Assoc 2017; 18:928-940. [PMID: 29080572 DOI: 10.1016/j.jamda.2017.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 01/09/2023]
Abstract
This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics covered are hypertension after the Systolic Blood Pressure Intervention Trial; chronic obstructive pulmonary disease risk factors, diagnosis and management including end-of-life planning, and the difficulties with exacerbations such as breathlessness; diagnosis and treatment of cognitive impairment and dementia; and wound care and pressure ulcer management.
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Affiliation(s)
| | - Milta O Little
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO.
| | - Julie K Gammack
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO
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Fernandes FLA, Cukier A, Camelier AA, Fritscher CC, da Costa CH, Pereira EDB, Godoy I, Cançado JED, Romaldini JG, Chatkin JM, Jardim JR, Rabahi MF, de Nucci MCNM, Sales MDPU, Castellano MVCDO, Aidé MA, Teixeira PJZ, Maciel R, Corrêa RDA, Stirbulov R, Athanazio RA, Russo R, Minamoto ST, Lundgren FLC. Recommendations for the pharmacological treatment of COPD: questions and answers. J Bras Pneumol 2017; 43:290-301. [PMID: 29365005 PMCID: PMC5687967 DOI: 10.1590/s1806-37562017000000153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/04/2017] [Indexed: 11/22/2022] Open
Abstract
The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities.
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Affiliation(s)
- Frederico Leon Arrabal Fernandes
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Alberto Cukier
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Aquiles Assunção Camelier
- . Universidade do Estado da Bahia - UNEB - Salvador (BA) Brasil
- . Escola Bahiana de Medicina e Saúde Pública, Salvador (BA) Brasil
| | - Carlos Cezar Fritscher
- . Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS− Porto Alegre (RS)Brasil
| | | | | | - Irma Godoy
- . Departamento de Medicina Interna, Área de Pneumologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | | | - José Gustavo Romaldini
- . Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo,São Paulo (SP) Brasil
| | - Jose Miguel Chatkin
- . Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS− Porto Alegre (RS)Brasil
| | - José Roberto Jardim
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | | | | | | | | | - Miguel Abidon Aidé
- . Faculdade de Medicina, Universidade Federal Fluminense, Niterói (RJ) Brasil
| | - Paulo José Zimermann Teixeira
- . Departamento de Clínica Médica, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil
- . Universidade FEEVALE, Campus II, Novo Hamburgo (RS) Brasil
| | - Renato Maciel
- . Disciplina de Pneumologia, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte (MG) Brasil
| | - Ricardo de Amorim Corrêa
- . Faculdade de Medicina, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | - Roberto Stirbulov
- . Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo,São Paulo (SP) Brasil
| | - Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rodrigo Russo
- . Departamento de Medicina, Universidade Federal de São João Del Rei - UFSJ − São João Del Rei (MG) Brasil
| | - Suzana Tanni Minamoto
- . Departamento de Medicina Interna, Área de Pneumologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
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De la Rosa D, Martínez-Garcia MA, Giron RM, Vendrell M, Olveira C, Borderias L, Maiz L, Torres A, Martinez-Moragon E, Rajas O, Casas F, Cordovilla R, de Gracia J. Clinical impact of chronic obstructive pulmonary disease on non-cystic fibrosis bronchiectasis. A study on 1,790 patients from the Spanish Bronchiectasis Historical Registry. PLoS One 2017; 12:e0177931. [PMID: 28542286 PMCID: PMC5436841 DOI: 10.1371/journal.pone.0177931] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 05/05/2017] [Indexed: 11/24/2022] Open
Abstract
Background Few studies have evaluated the coexistence of bronchiectasis (BE) and chronic obstructive pulmonary disease (COPD) in series of patients diagnosed primarily with BE. The aim of this study was to analyse the characteristics of patients with BE associated with COPD included in the Spanish Bronchiectasis Historical Registry and compare them to the remaining patients with non-cystic fibrosis BE. Methods We conducted a multicentre observational study of historical cohorts, analysing the characteristics of 1,790 patients who had been included in the registry between 2002 and 2011. Of these, 158 (8.8%) were registered as BE related to COPD and were compared to the remaining patients with BE of other aetiologies. Results Patients with COPD were mostly male, older, had a poorer respiratory function and more frequent exacerbations. There were no differences in the proportion of patients with chronic bronchial colonisation or in the isolated microorganisms. A significantly larger proportion of patients with COPD received treatment with bronchodilators, inhaled steroids and intravenous antibiotics, but there was no difference in the use of long term oral or inhaled antibiotherapy. During a follow-up period of 3.36 years, the overall proportion of deaths was 13.8%. When compared to the remaining aetiologies, patients with BE associated with COPD presented the highest mortality rate. The multivariate analysis showed that the diagnosis of COPD in a patient with BE as a primary diagnosis increased the risk of death by 1.77. Conclusion Patients with BE related to COPD have the same microbiological characteristics as patients with BE due to other aetiologies. They receive treatment with long term oral and inhaled antibiotics aimed at controlling chronic bronchial colonisation, even though the current COPD treatment guidelines do not envisage this type of therapy. These patients’ mortality is notably higher than that of remaining patients with non-cystic fibrosis BE.
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Affiliation(s)
- David De la Rosa
- Department of Pneumology, Hospital Plató, Barcelona, Spain
- * E-mail:
| | | | - Rosa Maria Giron
- Departament of Pneumology, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
| | - Montserrat Vendrell
- Department of Pneumology, Hospital Josep Trueta Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Casilda Olveira
- Department of Pneumology, Hospital Regional Universitario de Málaga, Instituto de Biomedicina de Málaga (IBIMA), Facultad de Medicina de Málaga, Spain
| | - Luis Borderias
- Department of Pneumology, Hospital General San Jorge, Huesca, Spain
| | - Luis Maiz
- Department of Pneumology, Hospital Ramón y Cajal, Madrid, Spain
| | - Antoni Torres
- Respiratory Institute, Hospital Clinic i Provincial, Barcelona, Spain
| | | | - Olga Rajas
- Departament of Pneumology, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
| | - Francisco Casas
- Department of Pneumology, Hospital Universitario San Cecilio, Granada, Spain
| | - Rosa Cordovilla
- Department of Pneumology, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Javier de Gracia
- Department of Pneumology, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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Asthma Yardstick. Ann Allergy Asthma Immunol 2017; 118:133-142.e3. [DOI: 10.1016/j.anai.2016.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/13/2023]
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Miravitlles M, D'Urzo A, Singh D, Koblizek V. Pharmacological strategies to reduce exacerbation risk in COPD: a narrative review. Respir Res 2016; 17:112. [PMID: 27613392 PMCID: PMC5018159 DOI: 10.1186/s12931-016-0425-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 08/20/2016] [Indexed: 01/17/2023] Open
Abstract
Identifying patients at risk of exacerbations and managing them appropriately to reduce this risk represents an important clinical challenge. Numerous treatments have been assessed for the prevention of exacerbations and their efficacy may differ by patient phenotype. Given their centrality in the treatment of COPD, there is strong rationale for maximizing bronchodilation as an initial strategy to reduce exacerbation risk irrespective of patient phenotype. Therefore, in patients assessed as frequent exacerbators (>1 exacerbation/year) we propose initial bronchodilator treatment with a long-acting muscarinic antagonist (LAMA)/ long-acting β2-agonist (LABA). For those patients who continue to experience >1 exacerbation/year despite maximal bronchodilation, we advocate treating according to patient phenotype. Based on currently available data on adding inhaled corticosteroids (ICS) to a LABA, ICS might be added to a LABA/LAMA combination in exacerbating patients who have an asthma-COPD overlap syndrome or high blood eosinophil counts, while in exacerbators with chronic bronchitis, consideration should be given to treating with a phosphodiesterase (PDE)-4 inhibitor (roflumilast) or high-dose mucolytic agents. For those patients who experience frequent bacterial exacerbations and/or bronchiectasis, addition of mucolytic agents or a macrolide antibiotic (e.g. azithromycin) should be considered. In all patients at risk of exacerbations, pulmonary rehabilitation should be included as part of a comprehensive management plan.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital General Universitari Vall d'Hebron, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Anthony D'Urzo
- Department of Family and Community Medicine, University of Toronto, 1670 Dufferin Street, Suite 107, Toronto, ON, M6H 3M2, Canada
| | - Dave Singh
- University of Manchester, Medicines Evaluation Unit, University Hospital of South Manchester Foundation Trust, Southmoor Road, Manchester, M23 9QZ, UK
| | - Vladimir Koblizek
- Department of Pneumology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Simkova 870, Hradec Kralove 1, 500 38, Czech Republic
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Singh D, Roche N, Halpin D, Agusti A, Wedzicha JA, Martinez FJ. Current Controversies in the Pharmacological Treatment of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2016; 194:541-9. [DOI: 10.1164/rccm.201606-1179pp] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Harada T, Ishimatsu Y, Hara A, Morita T, Nakashima S, Kakugawa T, Sakamoto N, Kosai K, Izumikawa K, Yanagihara K, Mukae H, Kohno S. Premedication with Clarithromycin Is Effective against Secondary Bacterial Pneumonia during Influenza Virus Infection in a Pulmonary Emphysema Mouse Model. J Pharmacol Exp Ther 2016; 358:457-63. [PMID: 27489022 DOI: 10.1124/jpet.116.233932] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 07/06/2016] [Indexed: 02/02/2023] Open
Abstract
Secondary bacterial pneumonia (SBP) during influenza increases the severity of chronic obstructive pulmonary disease (COPD) and its associated mortality. Macrolide antibiotics, including clarithromycin (CAM), are potential treatments for a variety of chronic respiratory diseases owing to their pharmacological activities, in addition to antimicrobial action. We examined the efficacy of CAM for the treatment of SBP after influenza infection in COPD. Specifically, we evaluated the effect of CAM in elastase-induced emphysema mice that were inoculated with influenza virus (strain A/PR8/34) and subsequently infected with macrolide-resistant Streptococcus pneumoniae CAM was administered to the emphysema mice 4 days prior to influenza virus inoculation. Premedication with CAM improved pathologic responses and bacterial load 2 days after S. pneumoniae inoculation. Survival rates were higher in emphysema mice than control mice. While CAM premedication did not affect viral titers or exert antibacterial activity against S. pneumoniae in the lungs, it enhanced host defense and reduced inflammation, as evidenced by the significant reductions in total cell and neutrophil counts and interferon (IFN)-γ levels in bronchoalveolar lavage fluid and lung homogenates. These results suggest that CAM protects against SBP during influenza in elastase-induced emphysema mice by reducing IFN-γ production, thus enhancing immunity to SBP, and by decreasing neutrophil infiltration into the lung to prevent injury. Accordingly, CAM may be an effective strategy to prevent secondary bacterial pneumonia in COPD patients in areas in which vaccines are inaccessible or limited.
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Affiliation(s)
- Tatsuhiko Harada
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Yuji Ishimatsu
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Atsuko Hara
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Towako Morita
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Shota Nakashima
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Tomoyuki Kakugawa
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Noriho Sakamoto
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Kosuke Kosai
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Koichi Izumikawa
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Katsunori Yanagihara
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Hiroshi Mukae
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
| | - Shigeru Kohno
- Department of Infectious Diseases, Unit of Molecular Microbiology and Immunology (T.H., K.I.), Department of Cardiopulmonary Rehabilitation Sciences (Y.I.), Department of Respiratory Medicine (N.S., H.M.), and Department of Laboratory Medicine (K.K, K.Y.), Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan (T.H., A.H., T.M., S.N., T.K., N.S., H.M., S.K.)
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Head K, Chong LY, Piromchai P, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Systemic and topical antibiotics for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011994. [PMID: 27113482 PMCID: PMC8763400 DOI: 10.1002/14651858.cd011994.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Systemic and topical antibiotics are used with the aim of eliminating infection in the short term (and some to reduce inflammation in the long term), in order to normalise nasal mucus and improve symptoms. OBJECTIVES To assess the effects of systemic and topical antibiotics in people with chronic rhinosinusitis. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; CENTRAL (2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing systemic or topical antibiotic treatment to (a) placebo or (b) no treatment or (c) other pharmacological interventions. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - gastrointestinal disturbance. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of suspected allergic reaction (rash or skin irritation) and anaphylaxis or other very serious reactions. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included five RCTs (293 participants), all of which compared systemic antibiotics with placebo or another pharmacological intervention.The varying study characteristics made comparison difficult. Four studies recruited only adults and one only children. Three used macrolide, one tetracycline and one a cephalosporin-type antibiotic. Three recruited only patients with chronic rhinosinusitis without nasal polyps, one recruited patients with chronic rhinosinusitis with nasal polyps and one had a mixed population. Three followed up patients for 10 to 12 weeks after treatment had finished. Systemic antibiotics versus placebo Three studies compared antibiotics with placebo (176 participants).One study (64 participants, without polyps) reported disease-specific HRQL using the SNOT-20 (0 to 5, 0 = best quality of life). At the end of treatment (three months) the SNOT-20 score was lower in the group receiving macrolide antibiotics than the placebo group (mean difference (MD) -0.54 points, 95% confidence interval (CI) -0.98 to -0.10), corresponding to a moderate effect size favouring antibiotics (moderate quality evidence). Three months after treatment, it is uncertain if there was a difference between groups.One study (33 participants, with polyps) provided information on gastrointestinal disturbances and suspected allergic reaction (rash or skin irritation) after a short course of tetracycline antibiotic compared with placebo. We are very uncertain if antibiotics were associated with an increase in gastrointestinal disturbances (risk ratio (RR) 1.36, 95% CI 0.22 to 8.50) or skin irritation (RR 6.67, 95% CI 0.34 to 128.86) (very low quality evidence). Systemic antibiotics plus saline irrigation and intranasal corticosteroids versus placebo plus saline irrigation and intranasal corticosteroids One study (60 participants, some with and some without polyps) compared a three-month course of macrolide antibiotic with placebo; all participants also used saline irrigation and 70% used intranasal corticosteroids. Disease-specific HRQL was reported using SNOT-22 (0 to 110, 0 = best quality of life). Data were difficult to interpret (highly skewed and baseline imbalances) and it is unclear if there was an important difference at any time point (low quality evidence). To assess patient-reported disease severity participants rated the effect of treatment on a five-point scale (-2 for "desperately worse" to 2 for "cured") at the end of treatment (three months). For improvement in symptoms there was no difference between the antibiotics and placebo groups; the RR was 1.50 (95% CI 0.81 to 2.79; very low quality evidence), although there were also slightly more people who felt worse after treatment in the antibiotics group. There was no demonstrable difference in the rate of gastrointestinal disturbances between the groups (RR 1.07, 95% CI 0.16 to 7.10). General HRQL was measured using the SF-36. The authors stated that there was no difference between groups at the end of treatment (12 weeks) or two weeks later. Systemic antibiotics versus intranasal corticosteroids One study (43 participants, without polyps) compared a three-month course of macrolide antibiotic with intranasal corticosteroids. Patient-reported disease severity was assessed using a composite symptom score (0 to 40; 0 = no symptoms). It is very uncertain if there was a difference as patient-reported disease severity was similar between groups (MD -0.32, 95% CI -2.11 to 1.47; low quality evidence). Systemic antibiotics versus oral corticosteroids One study (28 participants, with polyps) compared a short course of tetracycline antibiotic (unclear duration, ˜20 days) with a 20-day course of oral corticosteroids. We were unable to extract data on any of the primary efficacy outcomes. It is uncertain if there was a difference ingastrointestinal disturbances (RR 1.00, 95% CI 0.16 to 6.14) or skin irritation (RR 2.00, 95% CI 0.20 to 19.62) as the results for these outcomes were similar between groups (very low quality evidence). AUTHORS' CONCLUSIONS We found very little evidence that systemic antibiotics are effective in patients with chronic rhinosinusitis. We did find moderate quality evidence of a modest improvement in disease-specific quality of life in adults with chronic rhinosinusitis without polyps receiving three months of a macrolide antibiotic. The size of improvement was moderate (0.5 points on a five-point scale) and only seen at the end of the three-month treatment; by three months later no difference was found.Despite a general understanding that antibiotics can be associated with adverse effects, including gastrointestinal disturbances, the results in this review were very uncertain because the studies were small and few events were reported.No RCTs of topical antibiotics met the inclusion criteria.More research in this area, particularly evaluating longer-term outcomes and adverse effects, is required.
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Affiliation(s)
- Karen Head
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Lee Yee Chong
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Patorn Piromchai
- Faculty of Medicine, Khon Kaen UniversityDepartment of OtorhinolaryngologyKhon KaenThailand
| | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
| | - Martin J Burton
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
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Vermeersch K, Gabrovska M, Deslypere G, Demedts IK, Slabbynck H, Aumann J, Ninane V, Verleden GM, Troosters T, Bogaerts K, Brusselle GG, Janssens W. The Belgian trial with azithromycin for acute COPD exacerbations requiring hospitalization: an investigator-initiated study protocol for a multicenter, randomized, double-blind, placebo-controlled trial. Int J Chron Obstruct Pulmon Dis 2016; 11:687-96. [PMID: 27099485 PMCID: PMC4820219 DOI: 10.2147/copd.s95501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Long-term use of macrolide antibiotics is effective to prevent exacerbations in chronic obstructive pulmonary disease (COPD). As risks and side effects of long-term intervention outweigh the benefits in the general COPD population, the optimal dose, duration of treatment, and target population are yet to be defined. Hospitalization for an acute exacerbation (AE) of COPD may offer a targeted risk group and an obvious risk period for studying macrolide interventions. Methods/design Patients with COPD, hospitalized for an AE, who have a smoking history of ≥10 pack-years and had ≥1 exacerbation in the previous year will be enrolled in a multicenter, randomized, double-blind, placebo-controlled trial (NCT02135354). On top of a standardized treatment of systemic corticosteroids and antibiotics, subjects will be randomized to receive either azithromycin or placebo during 3 months, at an uploading dose of 500 mg once a day for 3 days, followed by a maintenance dose of 250 mg once every 2 days. The primary endpoint is the time-to-treatment failure during the treatment phase (ie, from the moment of randomization until the end of intervention). Treatment failure is a novel composite endpoint defined as either death, the admission to intensive care or the requirement of additional systemic steroids or new antibiotics for respiratory reasons, or the diagnosis of a new AE after discharge. Discussion We investigate whether azithromycin initiated at the onset of a severe exacerbation, with a limited duration and at a low dose, might be effective and safe in the highest risk period during and immediately after the acute event. If proven effective and safe, this targeted approach may improve the treatment of severe AEs and redirect the preventive use of azithromycin in COPD to a temporary intervention in the subgroup with the highest unmet needs.
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Affiliation(s)
- Kristina Vermeersch
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium
| | - Maria Gabrovska
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Brussels, Belgium
| | - Griet Deslypere
- Department of Pneumology, Jessa Ziekenhuis, Hasselt, Belgium
| | - Ingel K Demedts
- Department of Respiratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Hans Slabbynck
- Department of Respiratory Medicine, ZNA Middelheim, Antwerpen, Belgium
| | - Joseph Aumann
- Department of Pneumology, Jessa Ziekenhuis, Hasselt, Belgium
| | - Vincent Ninane
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Brussels, Belgium
| | - Geert M Verleden
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium
| | - Thierry Troosters
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium; KU Leuven, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Leuven, Belgium
| | - Kris Bogaerts
- KU Leuven, Department of Public Health and Primary Care, I-BioStat, Leuven, Belgium; Hasselt University, Hasselt, Belgium
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Wim Janssens
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium
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Severe acute exacerbations of chronic obstructive pulmonary disease: does the dosage of corticosteroids and type of antibiotic matter? Curr Opin Pulm Med 2016; 21:142-8. [PMID: 25575365 DOI: 10.1097/mcp.0000000000000142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are significant events that result in substantial morbidity and mortality. Antibiotic therapy and systemic corticosteroids are important treatments for patients with severe AECOPD. The objective of this review is to summarize the most recent evidence concerning antibiotic and corticosteroid therapy, with a focused evaluation on the contribution of antibiotic type and corticosteroid dosage on patient outcomes. RECENT FINDINGS Macrolides should be considered the antibiotic of choice for prevention of AECOPD in patients who qualify for therapy. Macrolides, fluoroquinolones, and beta-lactams are all reasonable treatment options for severe AECOPD and the decision to use one over the other should be based upon patient characteristics and institutional or regional antimicrobial susceptibility patterns. The best available evidence now suggests that higher-dose corticosteroids are not superior to treatment with lower-dose corticosteroids in patients with severe AECOPD. Additionally, longer durations of systemic corticosteroid therapy do not improve clinical outcomes. SUMMARY Several antibiotic options are efficacious in the management of severe AECOPD and drug selection should be patient-specific. Recent studies suggest that lower dosages and shorter durations of corticosteroid treatment may be prudent.
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31
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Arenas A, Rada G. Are prophylactic antibiotics useful in chronic obstructive pulmonary disease? Medwave 2015; 15 Suppl 3:e6309. [PMID: 26571418 DOI: 10.5867/medwave.2015.6309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Bacterial infections are one of the main causes of chronic obstructive pulmonary disease exacerbation, so the use of prophylactic antibiotics, especially macrolides, has been proposed in these patients. However, it is unclear whether antibiotics use is worth the risk and cost. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified five systematic reviews including eight randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded prophylactic antibiotics probably decrease exacerbations in chronic obstructive pulmonary disease, but have no effect on hospitalizations or mortality.
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Affiliation(s)
- Alex Arenas
- Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile.
| | - Gabriel Rada
- Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile; Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; GRADE working group; The Cochrane Collaboration
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Rooney C, Sethi T. Biomarkers for precision medicine in airways disease. Ann N Y Acad Sci 2015; 1346:18-32. [PMID: 26099690 DOI: 10.1111/nyas.12809] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/12/2015] [Accepted: 05/13/2015] [Indexed: 12/22/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a complex clinical entity. In contrast to previously limited diagnostic definitions, it is now apparent that COPD is a clinically and biologically heterogeneous disease process, overlapping with other airways diseases like chronic asthma. As such, symptomatic response to current standard treatment practices is variable. New clinical guidelines have been altered to reflect this, with the inclusion of symptoms and risk factors in diagnostic and management algorithms. However, as our understanding of COPD pathophysiology deepens, many novel physiological, cellular, proteomic, and genetic markers have been identified. Several have been observed to be independently predictive of distinct clinical disease patterns, which at present are not illustrated by conventional measurements of lung impairment. The potential use of these predictive biomarkers to stratify this diverse patient population could transform the care we offer. We should aim for precision medicine to optimize diagnosis and treatment choices and to monitor and improve clinical outcomes in this disease.
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Affiliation(s)
| | - Tariq Sethi
- Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom
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Tapilskaya NI, Karpeyev SA, Gaidukov SN. Justification of the efficacy of antibacterial therapy for the treatment of chronic endometritis. VESTNIK DERMATOLOGII I VENEROLOGII 2015. [DOI: 10.25208/0042-4609-2015-91-2-130-138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
A review of studies on chronic endometritis enables the authors to conclude that bacterially contaminated endometrium is the reason causing reduced fertility in case of confirmed subclinical inflammation. Chronic subclinical inflammation of the endometrium is often associated with genital endometriosis, which apparently leads to abnormal uterine bleedings. The identification of a microbial agent in case of endometritis in the routine outpatient practice is not mandatory because global experience including high-level evidence-based studies confirms the expediency of an empirical therapy based on minimum clinical criteria; otherwise, there may be irreversible consequences for the reproductive system. A preventive antibacterial therapy during the pre-conception period in infertile patients suffering from recurrent miscarriages is an efficient method to prevent reproductive losses.
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Kankaanranta H, Harju T, Kilpeläinen M, Mazur W, Lehto JT, Katajisto M, Peisa T, Meinander T, Lehtimäki L. Diagnosis and pharmacotherapy of stable chronic obstructive pulmonary disease: the finnish guidelines. Basic Clin Pharmacol Toxicol 2015; 116:291-307. [PMID: 25515181 PMCID: PMC4409821 DOI: 10.1111/bcpt.12366] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 12/07/2014] [Indexed: 12/18/2022]
Abstract
The Finnish Medical Society Duodecim initiated and managed the update of the Finnish national guideline for chronic obstructive pulmonary disease (COPD). The Finnish COPD guideline was revised to acknowledge the progress in diagnosis and management of COPD. This Finnish COPD guideline in English language is a part of the original guideline and focuses on the diagnosis, assessment and pharmacotherapy of stable COPD. It is intended to be used mainly in primary health care but not forgetting respiratory specialists and other healthcare workers. The new recommendations and statements are based on the best evidence available from the medical literature, other published national guidelines and the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. This guideline introduces the diagnostic approach, differential diagnostics towards asthma, assessment and treatment strategy to control symptoms and to prevent exacerbations. The pharmacotherapy is based on the symptoms and a clinical phenotype of the individual patient. The guideline defines three clinically relevant phenotypes including the low and high exacerbation risk phenotypes and the neglected asthma-COPD overlap syndrome (ACOS). These clinical phenotypes can help clinicians to identify patients that respond to specific pharmacological interventions. For the low exacerbation risk phenotype, pharmacotherapy with short-acting β2 -agonists (salbutamol, terbutaline) or anticholinergics (ipratropium) or their combination (fenoterol-ipratropium) is recommended in patients with less symptoms. If short-acting bronchodilators are not enough to control symptoms, a long-acting β2 -agonist (formoterol, indacaterol, olodaterol or salmeterol) or a long-acting anticholinergic (muscarinic receptor antagonists; aclidinium, glycopyrronium, tiotropium, umeclidinium) or their combination is recommended. For the high exacerbation risk phenotype, pharmacotherapy with a long-acting anticholinergic or a fixed combination of an inhaled glucocorticoid and a long-acting β2 -agonist (budesonide-formoterol, beclomethasone dipropionate-formoterol, fluticasone propionate-salmeterol or fluticasone furoate-vilanterol) is recommended as a first choice. Other treatment options for this phenotype include combination of long-acting bronchodilators given from separate inhalers or as a fixed combination (glycopyrronium-indacaterol or umeclidinium-vilanterol) or a triple combination of an inhaled glucocorticoid, a long-acting β2 -agonist and a long-acting anticholinergic. If the patient has severe-to-very severe COPD (FEV1 < 50% predicted), chronic bronchitis and frequent exacerbations despite long-acting bronchodilators, the pharmacotherapy may include also roflumilast. ACOS is a phenotype of COPD in which there are features that comply with both asthma and COPD. Patients belonging to this phenotype have usually been excluded from studies evaluating the effects of drugs both in asthma and in COPD. Thus, evidence-based recommendation of treatment cannot be given. The treatment should cover both diseases. Generally, the therapy should include at least inhaled glucocorticoids (beclomethasone dipropionate, budesonide, ciclesonide, fluticasone furoate, fluticasone propionate or mometasone) combined with a long-acting bronchodilator (β2 -agonist or anticholinergic or both).
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Affiliation(s)
- Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central HospitalSeinäjoki, Finland
- Department of Respiratory Medicine, University of TampereTampere, Finland
| | - Terttu Harju
- Department of Internal Medicine, Unit of Respiratory Medicine, Medical Research Center, Oulu University HospitalOulu, Finland
| | | | - Witold Mazur
- Heart and Lung Center, University of Helsinki and Helsinki University Central HospitalHelsinki, Finland
| | - Juho T Lehto
- Department of Palliative Medicine, University of TampereTampere, Finland
- Department of Oncology, Tampere University HospitalTampere, Finland
| | - Milla Katajisto
- Heart and Lung Center, University of Helsinki and Helsinki University Central HospitalHelsinki, Finland
| | | | - Tuula Meinander
- Finnish Medical Society DuodecimHelsinki, Finland
- Department of Internal Medicine, Tampere University HospitalTampere, Finland
| | - Lauri Lehtimäki
- Department of Respiratory Medicine, University of TampereTampere, Finland
- Allergy Centre, Tampere University HospitalTampere, Finland
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Ni W, Shao X, Cai X, Wei C, Cui J, Wang R, Liu Y. Prophylactic use of macrolide antibiotics for the prevention of chronic obstructive pulmonary disease exacerbation: a meta-analysis. PLoS One 2015; 10:e0121257. [PMID: 25812085 PMCID: PMC4374882 DOI: 10.1371/journal.pone.0121257] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/29/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) can lead to high frequencies and rates of hospitalization and mortality. Macrolides are a class of antibiotics that possess both antimicrobial and anti-inflammatory properties. Since the occurrence of AECOPDs is associated with aggravation of airway inflammation and bacterial infections, prophylactic macrolide treatment may be an effective approach towards the prevention of AECOPDs. METHODS We systemically searched the PubMed, Embase and Cochrane Library databases to identify randomized controlled trials (RCTs) that evaluated the effect of prophylactic macrolide therapy on the prevention of AECOPDs. The primary outcomes were the total number of patients with one or more exacerbations as well as the rate of exacerbations per patient per year. RESULTS Nine RCTs comprising 1666 patients met the inclusion criteria. Pooled evidence showed macrolides could reduce the frequency of exacerbations in patients with COPD by both unweighted (RR = 0.70; 95% CI: 0.56-0.87; P < 0.01) and weighted approaches (RR = 0.58, 95% CI: 0.43-0.78, P < 0.01). Subgroup analysis showed only 6-12 months of erythromycin or azithromycin therapy could be effective. Moreover, among studies with 6-12 months of azithromycin therapy, both the daily dosing regimen and the intermittent regimen significantly reduced exacerbation rates. The overall number of hospitalizations and the all-cause rate of death were not significantly different between the treatment and control groups. A tendency for more adverse events was found in the treatment groups (OR = 1.55, 95%CI: 1.003-2.39, P = 0.049). CONCLUSIONS Our results suggest 6-12 months erythromycin or azithromycin therapy could effectively reduce the frequency of exacerbations in patients with COPD. However, Long-term treatment may bring increased adverse events and the emergence of macrolide-resistance. A recommendation for the prophylactic use of macrolide therapy should weigh both the advantages and disadvantages.
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Affiliation(s)
- Wentao Ni
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Xiaodi Shao
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Xuejiu Cai
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Chuanqi Wei
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Junchang Cui
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Rui Wang
- Department of Clinical Pharmacology, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Youning Liu
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
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Montes de Oca M, López Varela MV, Acuña A, Schiavi E, Rey MA, Jardim J, Casas A, Tokumoto A, Torres Duque CA, Ramírez-Venegas A, García G, Stirbulov R, Camelier A, Bergna M, Cohen M, Guzmán S, Sánchez E. ALAT-2014 Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines: questions and answers. Arch Bronconeumol 2015; 51:403-16. [PMID: 25596991 DOI: 10.1016/j.arbres.2014.11.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/10/2014] [Accepted: 11/17/2014] [Indexed: 11/17/2022]
Abstract
ALAT-2014 COPD Clinical Practice Guidelines used clinical questions in PICO format to compile evidence related to risk factors, COPD screening, disease prognosis, treatment and exacerbations. Evidence reveals the existence of risk factors for COPD other than tobacco, as well as gender differences in disease presentation. It shows the benefit of screening in an at-risk population, and the predictive value use of multidimensional prognostic indexes. In stable COPD, similar benefits in dyspnea, pulmonary function and quality of life are achieved with LAMA or LABA long-acting bronchodilators, whereas LAMA is more effective in preventing exacerbations. Dual bronchodilator therapy has more benefits than monotherapy. LAMA and combination LABA/IC are similarly effective, but there is an increased risk of pneumonia with LABA/IC. Data on the efficacy and safety of triple therapy are scarce. Evidence supports influenza vaccination in all patients and anti-pneumococcal vaccination in patients <65years of age and/or with severe airflow limitation. Antibiotic prophylaxis may decrease exacerbation frequency in patients at risk. The use of systemic corticosteroids and antibiotics are justified in exacerbations requiring hospitalization and in some patients managed in an outpatient setting.
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Affiliation(s)
- María Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela.
| | | | - Agustín Acuña
- Hospital Universitario de Caracas, Universidad Central de Venezuela, y Centro Médico Docente La Trinidad, Caracas, Venezuela
| | - Eduardo Schiavi
- Hospital de Rehabilitación Respiratoria «María Ferrer», Buenos Aires, Argentina
| | | | - José Jardim
- Universidade Federal de São Paulo, São Paulo, Brasil
| | | | | | | | | | | | - Roberto Stirbulov
- Facultad de Ciencias Médicas, Santa Casa de San Pablo, São Paulo, Brasil
| | - Aquiles Camelier
- Universidade Federal da Bahia e Escola Bahiana de Medicina, Salvador, Brasil
| | - Miguel Bergna
- Hospital Dr. Antonio Cetrángolo, Vicente López, Buenos Aires, Argentina
| | - Mark Cohen
- Hospital Centro Médico, Guatemala, Guatemala
| | | | - Efraín Sánchez
- Hospital Universitario de Caracas, Universidad Central de Venezuela, y Centro Médico Docente La Trinidad, Caracas, Venezuela
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Wong EHC, Porter JD, Edwards MR, Johnston SL. The role of macrolides in asthma: current evidence and future directions. THE LANCET RESPIRATORY MEDICINE 2014; 2:657-70. [PMID: 24948430 DOI: 10.1016/s2213-2600(14)70107-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Macrolides, such as clarithromycin and azithromycin, possess antimicrobial, immunomodulatory, and potential antiviral properties. They represent a potential therapeutic option for asthma, a chronic inflammatory disorder characterised by airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. Results from clinical trials, however, have been contentious. The findings could be confounded by many factors, including the heterogeneity of asthma, treatment duration, dose, and differing outcome measures. Recent evidence suggests improved effectiveness of macrolides in patients with sub-optimally controlled severe neutrophilic asthma and in asthma exacerbations. We examine the evidence from clinical trials and discuss macrolide properties and their relevance to the pathophysiology of asthma. At present, the use of macrolides in chronic asthma or acute exacerbations is not justified. Further work, including proteomic, genomic, and microbiome studies, will advance our knowledge of asthma phenotypes, and help to identify a macrolide-responsive subgroup. Future clinical trials should target this subgroup and place emphasis on clinically relevant outcomes such as asthma exacerbations.
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Affiliation(s)
- Ernie H C Wong
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - James D Porter
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK
| | - Michael R Edwards
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK
| | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK; Imperial College Healthcare NHS Trust, London, UK.
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Morton B, Pennington SH, Gordon SB. Immunomodulatory adjuvant therapy in severe community-acquired pneumonia. Expert Rev Respir Med 2014; 8:587-96. [PMID: 24898699 DOI: 10.1586/17476348.2014.927736] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Severe pneumonia has a high mortality (38.2%) despite evidence-based therapy. Rising rates of antimicrobial resistance increase the urgency to develop new treatment strategies. Multiple adjuvant therapies for pneumonia have been investigated but none are currently licensed. Profound immune dysregulation occurs in patients with severe infection. An initial hyper-inflammatory response is followed by a secondary hypo-inflammatory response with 'immune-paralysis'. There is focus on the development of immunostimulatory agents to improve host ability to combat primary infection and reduce secondary infections. Successful treatments must be targeted to immune response; promising biomarkers exist but have not yet reached common bedside practice. We explore evidence for adjuvant therapies in community-acquired pneumonia. We highlight novel potential treatment strategies using a broad-based search strategy to include publications in pneumonia and severe sepsis. We explore reasons for the failure to develop effective adjuvant therapies and highlight the need for targeted therapy specific to immune activity.
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Affiliation(s)
- Ben Morton
- Liverpool School of Tropical Medicine - Clinical Sciences, Pembroke Place, Liverpool L3 5QA, UK
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Macrolide treatment in patients with bronchiectasis: More attention should be paid to the number of exacerbations. Pulm Pharmacol Ther 2014; 27:213-4. [DOI: 10.1016/j.pupt.2013.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 12/23/2013] [Accepted: 12/25/2013] [Indexed: 11/23/2022]
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Meta-analysis of the adverse effects of long-term azithromycin use in patients with chronic lung diseases. Antimicrob Agents Chemother 2013; 58:511-7. [PMID: 24189261 DOI: 10.1128/aac.02067-13] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The adverse effects of azithromycin on the treatment of patients with chronic lung diseases (CLD) were evaluated in the present study. MEDLINE and other databases were searched for relevant articles published until August 2013. Randomized controlled trials that enrolled patients with chronic lung diseases who received long-term azithromycin treatment were selected, and data on microbiological studies and azithromycin-related adverse events were abstracted from articles and analyzed. Six studies were included in the meta-analysis. The risk of bacterial resistance in patients receiving long-term azithromycin treatment was increased 2.7-fold (risk ratio [RR], 2.69 [95% confidence interval {95% CI}, 1.249, 5.211]) compared with the risk in patients receiving placebo treatment. On the other hand, the risk of bacterial colonization decreased in patients receiving azithromycin treatment (RR, 0.551 [95% CI, 0.460, 0.658]). Patients receiving long-term azithromycin therapy were at risk of increased impairment of hearing (RR, 1.168 [95% CI, 1.030, 1.325]). This analysis provides evidence supporting the idea that bacterial resistance can develop with long-term azithromycin treatment. Besides the increasingly recognized anti-inflammatory role of azithromycin used in treating chronic lung diseases, we should be aware of the potential for adverse events with its long-term use.
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Kuruvilla M, de la Morena MT. Antibiotic Prophylaxis in Primary Immune Deficiency Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:573-82. [DOI: 10.1016/j.jaip.2013.09.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/10/2013] [Accepted: 09/23/2013] [Indexed: 12/31/2022]
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