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Li J, Liang L, Samuel Cai Y, Zuo Y, Su J, Feng L, Wang H, Tong Z. Tracking COPD exacerbation patterns and forecasting readmission risks utilizing electronic medical records. Int J Med Inform 2024; 189:105505. [PMID: 38824858 DOI: 10.1016/j.ijmedinf.2024.105505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 05/25/2024] [Accepted: 05/26/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Accurate evaluation of exacerbation frequency is an essential part of COPD assessment. But relying on just the prior-year exacerbation history may not capture the full picture of risk given the inherent year-to-year fluctuations in exacerbation rates. This study aimed to evaluate the predictive performance of models incorporating the 3-year exacerbation history based on electronic medical record. MATERIALS AND METHODS This retrospective cohort study included 86,501 COPD hospitalized patients in Beijing from 2008 to 2014. The annual frequency of COPD exacerbation hospitalizations over a 3-year period after the index hospitalization was calculated, with patients segmented into seven distinct exacerbation trajectory groups. Logistic regression was used to evaluate the predictive capability of the 3-year exacerbation history for exacerbation readmission in the fourth year. Predictors included age, sex, comorbidities, and exacerbation hospitalization in previous 1-3 years. Model performance was evaluated using area under the receiver operating characteristic curve (AUC). RESULTS Of the studied patients, 56.5% were men, and the mean age (SD) was 73.8 (10.3) years. The overall readmission rate for COPD exacerbation was 0.31 per person-year, with only 3.8% of patients persistently readmitted over three consecutive years. The 3-year trajectory of exacerbation frequency was associated with exacerbation risk in the fourth year. Compared to just the prior year, the inclusion of a 3-year exacerbation hospitalization history notably improved prediction accuracy, with AUC elevating from 0.731 (0.724-0.739) to 0.786 (0.779-0.792). CONCLUSION These results unveil the fluctuating nature of COPD exacerbation hospitalization frequency across years and demonstrate that integrating a more comprehensive 3-year exacerbation history significantly refines the prediction model for future risk, thus providing a more nuanced and actionable insight for clinical care.
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Affiliation(s)
- Jiachen Li
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Lirong Liang
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Yutong Samuel Cai
- Centre for Environmental Health and Sustainability, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Yingting Zuo
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jian Su
- School of Economics, Peking University, Beijing, China
| | - Lin Feng
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | | | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Marott JL, Ingebrigtsen TS, Çolak Y, Vestbo J, Nordestgaard BG, Lange P. Predicting exacerbations in COPD in the Danish general population. Respir Med 2024; 224:107557. [PMID: 38355020 DOI: 10.1016/j.rmed.2024.107557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/12/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Risk of exacerbations in individuals with mild chronic obstructive pulmonary disease (COPD) in the general population is less well described than in more advanced disease. We hypothesized that in addition to history of previous exacerbation also other clinical characteristics predict future moderate exacerbations. METHODS In 96,462 individuals in the Copenhagen General Population Study, we identified 3175 with clinical COPD defined as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) < 0.70 and FEV1 <80% predicted in symptomatic individuals without asthma. We estimated the importance of age, sex, FEV1, modified Medical Research Council (mMRC) dyspnea scale, chronic bronchitis, exacerbation history, comorbidities, cohabitation, body mass index, smoking, and blood eosinophils for the 1-year and 3-year future risk of moderate COPD exacerbations and developed a prediction tool for future exacerbations in COPD in the general population based on easily available clinical information. RESULTS We observed 265 exacerbations in 2543 maintenance treatment naïve individuals with COPD and 197 exacerbations in 632 individuals with COPD on maintenance treatment. In the maintenance treatment naïve group, exacerbation history (hazard ratio (HR): 8.53), low FEV1 (HR: 4.82 for <30% predicted versus 50-79% predicted), and higher age (HR: 1.46 for ≥75 years versus <65 years) were significant predictors of future exacerbations. In the group on maintenance treatment, male sex and mMRC ≥2 also predicted higher risk with borderline significance. CONCLUSIONS In addition to exacerbation history also higher age and lower FEV1 predict future exacerbation risk in COPD in the general population.
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Affiliation(s)
- Jacob Louis Marott
- Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Copenhagen City Heart Study, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Truls Sylvan Ingebrigtsen
- Copenhagen City Heart Study, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Medical Department, Respiratory Section, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Yunus Çolak
- Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Medical Department, Respiratory Section, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, United Kingdom
| | - Børge Grønne Nordestgaard
- Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Copenhagen City Heart Study, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Biochemistry, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Peter Lange
- Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Copenhagen City Heart Study, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Medical Department, Respiratory Section, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark.
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Bhatt SP. Predicting Chronic Obstructive Pulmonary Disease Exacerbations: When the Past Does Not Inform the Future. Ann Am Thorac Soc 2024; 21:382-383. [PMID: 38426829 PMCID: PMC10913768 DOI: 10.1513/annalsats.202311-934ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Trajectories of Severe Exacerbations of Chronic Obstructive Pulmonary Disease and Their Relationship with Mortality Risk. Lung 2022; 200:601-607. [PMID: 36065068 DOI: 10.1007/s00408-022-00565-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/23/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Acute exacerbations of COPD (AECOPD) are important factors contributing to mortality risk. The rate of exacerbations varies overtime. An inconsistent pattern of exacerbation occurrence is a common finding. The mortality risk associated with such a pattern is not entirely clear. Our objective was to assess the risk of mortality associated with various possible patterns of AECOPD trajectories. METHODS This is a multicenter historical cohort study. Four different exacerbation trajectories were defined according to the incidence of severe AECOPD requiring hospital admission 2 years before and after the date of the first visit to the respiratory clinic-Consistent non-exacerbators (NEx): no AECOPD before or after the index date; consistent exacerbators (Ex): at least one AECOPD both before and after the index date; converters to exacerbators (CONV-Ex): no exacerbations before and at least one AECOPD after the index date; converters to non-exacerbators (CONV-NEx): at least one AECOPD before the index date, and no exacerbations after said date. All-cause mortality risk for these trajectories was assessed. RESULTS A total of 1713 subjects were included in the study: NEx: 1219 (71.2%), CONV-NEx: 225 (13.1%), CONV-Ex: 148 (8.6%), Ex: 121 (7.1%). After correcting for confounding variables, the group with the highest mortality risk was Ex. The CONV-Ex and CONV-Nex groups had a mortality risk between Ex and NEx, with no significant differences between them. CONCLUSION Different possible trajectories of severe AECOPD before and after a first specialized consultation are associated with different mortality risks. An inconsistent pattern of exacerbations has a mortality risk between Ex and NEx, with no clear differences between CONV-Ex and CONV-NEx.
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Abstract
Over the last 20 years, it has become possible to use a precision medicine approach to the management of chronic obstructive pulmonary disease (COPD). Clinical and physiological features as well as a blood biomarker can be used to target treatments to patients most likely to benefit and avoid treatment in patients less likely to benefit. Future advances in a precision medicine approach to COPD will depend on more precise characterization of individual patients, possibly using quantitative imaging, new physiological techniques, novel biomarkers and genetic profiling. Precision medicine has led to significant improvements in the management of COPD and clinicians should use all available information to optimize the treatment of individual patients.
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Exacerbation history, severity of dyspnoea and maintenance treatment predicts risk of future exacerbations in patients with COPD in the general population. Respir Med 2021; 192:106725. [PMID: 34972025 DOI: 10.1016/j.rmed.2021.106725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/03/2021] [Accepted: 12/19/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Whether risk of exacerbations of chronic obstructive pulmonary disease (COPD) is influenced by severity of symptoms and maintenance treatment is unclear. OBJECTIVE We hypothesized that in addition to history of exacerbations of COPD, the severity of dyspnoea and use of maintenance medications are associated with risk of future exacerbations. METHODS We included 96,462 adults from the Copenhagen General Population Study and assessed risk of moderate and severe exacerbations from 2003 to 2013 according to exacerbation history, dyspnoea score (mMRC), and presence/absence of maintenance treatment with inhaled long-acting bronchodilators and/or inhaled corticosteroids. FINDINGS Among 13,380 individuals with COPD, we observed 1543 moderate and 348 severe exacerbations. In treatment naïve individuals and in those on maintenance treatment, history of previous exacerbations and to a smaller degree also dyspnoea were associated with a higher risk of future exacerbations; 32% of the treatment naïve individuals with mMRC≥2 and a single moderate exacerbation in the previous year experienced a moderate exacerbation during the following year compared with only 3% in the individuals with similar severity of dyspnoea but no exacerbations in the previous year yielding an adjusted hazard ratio of 6.26 (95% confidence interval, 3.70-10.58). INTERPRETATION This observational study of the general population suggests that in addition to exacerbation history also the severity of dyspnoea predicts the risk of future COPD exacerbations. In subjects with severe dyspnoea, a history of a single moderate exacerbation is associated with a high risk of future exacerbations, suggesting that this subgroup needs special attention in order to prevent these events.
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Çolak Y, Afzal S, Marott JL, Nordestgaard BG, Vestbo J, Ingebrigtsen TS, Lange P. Prognosis of COPD depends on severity of exacerbation history: A population-based analysis. Respir Med 2019; 155:141-147. [PMID: 31362177 DOI: 10.1016/j.rmed.2019.07.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/22/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Differences in previous exacerbation history may influence prognosis of chronic obstructive pulmonary disease (COPD). We hypothesized that prognosis differs between individuals with a history of only medically treated exacerbations (moderate exacerbations) and those with a history of hospitalised exacerbations (severe exacerbations). METHODS We included 98 614 adults from the Copenhagen General Population Study and assessed risk of moderate and severe exacerbations, pneumonia hospitalisation, and respiratory and all-cause mortality from 2003 until 2013 according to exacerbation history. RESULTS Among 6545 individuals with COPD, 6290 had no exacerbations in the preceding year, 109 had one moderate exacerbation, 108 had two or more moderate exacerbations, and 38 had one or more severe exacerbations. During 9.4 years of follow-up, we observed 926 moderate and 244 severe exacerbations, 477 pneumonias, and 707 deaths, including 69 from respiratory disease. Compared to individuals without previous exacerbations, lung function and symptom adjusted hazard ratios (HRs) for future moderate exacerbation were 4.68 (95% confidence interval:3.31-6.62) for individuals with one previous moderate exacerbation, 21 (13-33) for individuals with two or more previous moderate exacerbations, and 5.30 (3.44-8.15) for individuals with one or more previous severe exacerbations. Corresponding HRs were 1.62(0.78-3.34), 1.29(0.57-2.89), and 5.43 (2.56-12) for severe exacerbation, 1.86(1.06-3.27), 1.74(1.01-2.99), and 4.85 (2.94-8.02) for pneumonia, 0.53(0.10-2.99), 1.65(0.53-5.17), and 2.98 (1.14-7.83) for respiratory mortality, and 1.34(0.79-2.29), 1.57(1.00-2.47), and 1.49 (0.85-2.62) for all-cause mortality, respectively. CONCLUSION Individuals with COPD and a history of hospitalised exacerbations carried the poorest prognosis compared to those with a history of only medically treated exacerbations, suggesting difference in risk profile.
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Affiliation(s)
- Yunus Çolak
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, and the Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Shoaib Afzal
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, and the Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jacob L Marott
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, and the Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, and the Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, And Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Truls S Ingebrigtsen
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, and the Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Medical Unit, Respiratory Section, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - Peter Lange
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, and the Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark; Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.
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Reilev M, Pottegård A, Lykkegaard J, Søndergaard J, Ingebrigtsen TS, Hallas J. Increased risk of major adverse cardiac events following the onset of acute exacerbations of COPD. Respirology 2019; 24:1183-1190. [PMID: 31222861 DOI: 10.1111/resp.13620] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/02/2019] [Accepted: 05/22/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute exacerbations in chronic obstructive pulmonary disease (COPD) may trigger major adverse cardiac events (MACE). We aimed to determine whether the risk of having MACE was transiently increased following the onset of an acute COPD exacerbation. METHODS We conducted a nationwide, register-based study from 1997 to 2014 comprising individuals with an acute COPD exacerbation followed by a MACE (acute myocardial infarction (MI), stroke or cardiovascular death). Using the case-crossover design, we estimated odds ratios (OR) for the association between acute exacerbations of COPD and MACE as well as for single outcomes (acute MI, stroke and cardiovascular death), different levels of severity of exacerbations and within patient subgroups. RESULTS We identified 118 807 cases with a MACE preceded by an exacerbation. Overall, the risk of MACE increased almost fourfold following the onset of an acute exacerbation compared to periods without exacerbations in the same individuals (OR: 3.70; 95% CI: 3.60-3.80). The associations were consistent for single outcomes (acute MI, OR: 3.57; cardiovascular death, OR: 4.33; and stroke, OR: 2.78) and particularly strong associations were demonstrated for severe exacerbations (OR: 5.92) and the oldest individuals (OR: 4.18). CONCLUSION The risk of MACE increased substantially following the onset of an acute exacerbation. This highlights that prevention of cardiac events is an important goal in the management of COPD. Attention should be paid to detecting cardiovascular disease following acute COPD exacerbations.
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Affiliation(s)
- Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark.,The Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- The Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jens Søndergaard
- The Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Truls S Ingebrigtsen
- Department of Respiratory Medicine, Hvidovre and Amager Hospitals, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Gulati S, Wells JM, Urdaneta GP, Balestrini K, Vital I, Tovar K, Barnes JW, Bhatt SP, Campos M, Krick S. Fibroblast Growth Factor 23 is Associated with a Frequent Exacerbator Phenotype in COPD: A Cross-Sectional Pilot Study. Int J Mol Sci 2019; 20:ijms20092292. [PMID: 31075857 PMCID: PMC6539353 DOI: 10.3390/ijms20092292] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 12/31/2022] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory airway disease punctuated by exacerbations (AECOPD). Subjects with frequent AECOPD, defined by having at least two exacerbations per year, experience accelerated loss of lung function, deterioration in quality of life and increase in mortality. Fibroblast growth factor (FGF)23, a hormone associated with systemic inflammation and altered metabolism is elevated in COPD. However, associations between FGF23 and AECOPD are unknown. In this cross-sectional study, individuals with COPD were enrolled between June 2016 and December 2016. Plasma samples were analyzed for intact FGF23 levels. Logistic regression analyses were used to measure associations between clinical variables, FGF23, and the frequent exacerbator phenotype. Our results showed that FGF23 levels were higher in frequent exacerbators as compared to patients without frequent exacerbations. FGF23 was also independently associated with frequent exacerbations (OR 1.02; 95%CI 1.004–1.04; p = 0.017), after adjusting for age, lung function, smoking, and oxygen use. In summary, FGF23 was associated with the frequent exacerbator phenotype and correlated with number of exacerbations recorded retrospectively and prospectively. Further studies are needed to explore the role of FGF 23 as a possible biomarker for AECOPD to better understand the pathobiology of COPD and to help develop therapeutic targets.
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Affiliation(s)
- Swati Gulati
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - J Michael Wells
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA.
- UAB Lung Health Center, Birmingham, AL 35294, USA.
- Birmingham VA Medical Center, Birmingham, AL 35294, USA.
| | - Gisel P Urdaneta
- Pulmonary Section, Miami VA Medical Center, Miami, FL 33125, USA.
| | - Kira Balestrini
- Pulmonary Section, Miami VA Medical Center, Miami, FL 33125, USA.
| | - Isabel Vital
- Pulmonary Section, Miami VA Medical Center, Miami, FL 33125, USA.
| | - Katherine Tovar
- Pulmonary Section, Miami VA Medical Center, Miami, FL 33125, USA.
| | - Jarrod W Barnes
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA.
- UAB Lung Health Center, Birmingham, AL 35294, USA.
| | - Michael Campos
- Pulmonary Section, Miami VA Medical Center, Miami, FL 33125, USA.
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL 33136, USA.
| | - Stefanie Krick
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Reilev M, Kristensen KB, Søndergaard J, Henriksen DP, Thompson W, Pottegård A. Discontinuation of therapy among COPD patients who experience an improvement in exacerbation status. Eur J Clin Pharmacol 2019; 75:1025-1032. [PMID: 30903196 DOI: 10.1007/s00228-019-02667-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/12/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE A subset of patients with chronic obstructive pulmonary disease (COPD) experience a decrease in exacerbation frequency, leading to a diminished need for treatment with inhaled corticosteroids (ICS). We investigated prescribing and discontinuation patterns of long-acting bronchodilators and ICS in COPD patients according to exacerbation frequency. METHODS Using the nationwide Danish health registries, we conducted a drug utilization study among patients who had at least two exacerbations or one hospitalization due to an exacerbation during 2011-2012. This study population was stratified according to consistency of exacerbation occurrence after 12, 24, 36, and 48 months of follow-up and the groups were described according to use of ICS, long-acting β2-agonists (LABA), and long-acting anticholinergics (LAMA), and combinations thereof. RESULTS We identified 29,010 COPD exacerbators during 2011-2012. Upon inclusion, 70% received ICS-containing regimens, in combination with LABA (23%) or both LABA and LAMA (41%). The proportion of prevalent users of ICS-containing regimens decreased to 56% during follow-up among exacerbation-free individuals, while it increased to 86% in individuals who experienced at least one exacerbation annually. Persistence to ICS-containing regimens was 58% after 4 years in individuals without exacerbations compared to 74% among those with annual exacerbations. Similar patterns were observed for triple therapy which was the most extensively used drug combination regardless of consistency of exacerbation occurrence. CONCLUSIONS The extensive use of ICS and the relatively high persistence to ICS-containing regimens in individuals who had a decrease in exacerbation occurrence highlight a need for the development and implementation of de-escalation strategies in clinical practice.
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Affiliation(s)
- Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark.
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark.
| | - Kasper Bruun Kristensen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
| | | | - Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
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Blagev DP, Collingridge DS, Rea S, Press VG, Churpek MM, Carey K, Mularski RA, Zeng S, Arjomandi M. Stability of Frequency of Severe Chronic Obstructive Pulmonary Disease Exacerbations and Health Care Utilization in Clinical Populations. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:208-220. [PMID: 30584584 DOI: 10.15326/jcopdf.5.3.2017.0183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Rationale: Although chronic obstructive pulmonary disease (COPD) exacerbation frequency is stable in research cohorts, whether severe COPD exacerbation frequency can be used to identify patients at high risk for future severe COPD exacerbations and/or mortality is unknown. Methods: Severe COPD exacerbation frequency stability was determined in 3 distinct clinical cohorts. A total of 17,450 patients with COPD in Intermountain Healthcare were categorized based on the number of severe COPD exacerbations per year. We determined whether exacerbation frequency was stable and whether it predicted mortality. These findings were validated in 83,134 patients from the U.S. Veterans Affairs (VA) nationwide health care system and 3326 patients from the University of Chicago Medicine health system. Results: In the Intermountain Healthcare cohort, the majority (84%, 14,706 patients) had no exacerbations in 2009 and were likely to remain non-exacerbators with a significantly lower 6-year mortality compared with frequent exacerbators (2 or more exacerbations per year) (25% versus 57%, p<0.001). Similar findings were noted in the VA health system and the University of Chicago Medicine health system. Non-exacerbators were likely to remain non-exacerbators with the lowest overall mortality. In all cohorts, frequent exacerbator was not a stable phenotype until patients had at least 2 consecutive years of frequent exacerbations. COPD exacerbation frequency predicted any cause mortality. Conclusions: In clinical datasets across different organizations, severe COPD exacerbation frequency was stable after at least 2 consecutive years of frequent exacerbations. Thus, severe COPD exacerbation frequency identifies patients across a health care system at high risk for future COPD-related health care utilization and overall mortality.
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Affiliation(s)
- Denitza P Blagev
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.,Division of Respiratory, Critical Care, and Sleep Medicine, Department of Medicine, University of Utah, Salt Lake City
| | - Dave S Collingridge
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.,Office of Research, Intermountain Healthcare, Salt Lake City, Utah
| | - Susan Rea
- Office of Research, Intermountain Healthcare, Salt Lake City, Utah.,Homer Warner Center for Informatics Research, Murray, Utah
| | - Valerie G Press
- Section of General Internal Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Matthew M Churpek
- Section of General Internal Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Kyle Carey
- Section of General Internal Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Richard A Mularski
- Kaiser Permanente Center for Health Research - Northwest, Portland, Oregon.,Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland
| | - Siyang Zeng
- Division of Pulmonary and Critical Care Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Pulmonary, Critical Care Allergy, Immunology and Sleep Medicine, Department of Medicine, University of California, San Francisco
| | - Mehrdad Arjomandi
- Division of Pulmonary and Critical Care Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Pulmonary, Critical Care Allergy, Immunology and Sleep Medicine, Department of Medicine, University of California, San Francisco
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Hurst JR, Anzueto A, Vestbo J. Susceptibility to exacerbation in COPD. THE LANCET RESPIRATORY MEDICINE 2018; 5:e29. [PMID: 28853400 DOI: 10.1016/s2213-2600(17)30307-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 07/26/2017] [Indexed: 11/18/2022]
Affiliation(s)
| | - Antonio Anzueto
- University of Texas Health Science Centre, San Antonio, TX, USA
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