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Villar Martínez M, Calvo Manuel E, Aguilar-Shea AL. [COPD inhaled therapy narrative review]. Semergen 2024; 50:102284. [PMID: 38925076 DOI: 10.1016/j.semerg.2024.102284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/13/2024] [Accepted: 04/07/2024] [Indexed: 06/28/2024]
Abstract
The basis of COPD maintenance treatment is the long-acting bronchodilators and the inhaled corticosteroids. Faced with the recent modifications in the clinical practice guidelines, we have carried out a review of studies that contrast the various therapeutic alternatives and pharmacological agents within each category, with the fundamental purpose of shedding light on which of these options prove to be more effective. Triple therapy stands out as essential in poorly controlled patients or with an eosinophilic phenotype, surpassing dual therapy. However, among the combinations of LAMA/LABA or LAMA/LABA/IC, no drug is observed to be superior in the reviewed evidence. Although triple therapies include corticosteroids, there does not appear to be a significant increase in side effects or pneumonia. Regarding monotherapy with LAMA, no significant differences are seen between the drugs, but in dual therapy with LABA/IC, the budesonide/formoterol combination seems to offer better control than fluticasone/salmeterol.
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Affiliation(s)
- M Villar Martínez
- Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, España.
| | - E Calvo Manuel
- Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, España
| | - A L Aguilar-Shea
- Medicina Familiar y Comunitaria, Centro de Salud Puerta de Madrid, Alcalá de Henares, Madrid, España
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Manzetti GM, Ora J, Sepiacci A, Cazzola M, Rogliani P, Calzetta L. Clinically Important Deterioration (CID) and Ageing in COPD: A Systematic Review and Meta-Regression Analysis According to PRISMA Statement. Int J Chron Obstruct Pulmon Dis 2023; 18:2225-2243. [PMID: 37841747 PMCID: PMC10576506 DOI: 10.2147/copd.s396945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023] Open
Abstract
Purpose Clinically important deterioration (CID) is a composite endpoint developed to quantify the impact of pharmacological treatment in clinical trials for Chronic Obstructive Pulmonary Disease (COPD), also showing a prognostic value. CID is defined as any of the following condition: forced expiratory volume in 1 s decrease ≥100 mL from baseline, and/or St. George's Respiratory Questionnaire total score increase ≥4-unit from baseline, and/or the occurrence of a moderate-to-severe exacerbation of COPD. Although most COPD patients experience a clinical worsening as they get older, to date, no specific studies assessed the correlation between ageing and CID in COPD. Therefore, the aim of this study was to investigate the impact of ageing on CID in COPD patients. Patients and Methods Data obtained from 55219 COPD patients were extracted from 17 papers, mostly post-hoc analyses. A pairwise meta-analysis and a meta-regression analysis were performed according to PRISMA-P guidelines to quantify the impact of pharmacological therapy on CID and to determine whether ageing might modulate the risk of CID in COPD patients. Results Inhaled treatments resulted generally effective in reducing the risk of CID in COPD (relative risk: 0.81, 95% confidence interval 0.79-0.84; P < 0.001). The meta-regression analysis indicated a trend toward significance (P = 0.063) in the linear relationship between age and the risk of CID. Of note, age significantly (P < 0.05) increased the risk of CID when associated with lower post-bronchodilator FEV1. These results were not affected by a significant risk of bias. Conclusion This quantitative synthesis suggests that inhaled therapy is effective in reducing the risk of CID in COPD, although such a protective effect may be affected in older patients with impaired lung function. Further studies specifically designed on CID in COPD are needed to confirm these results.
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Affiliation(s)
- Gian Marco Manzetti
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Josuel Ora
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Arianna Sepiacci
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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Huang WC, Lin SH, Hang LW, Lin CH, Hsu JY. The Effectiveness and Tolerability of Glycopyrronium for Patients with Chronic Obstructive Pulmonary Disease in a Clinical Setting: GLARE-Taiwan. J Clin Med 2022; 11:jcm11206210. [PMID: 36294532 PMCID: PMC9604569 DOI: 10.3390/jcm11206210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Glycopyrronium (GLY) is a pharmacological maintenance treatment for chronic obstructive pulmonary disease (COPD). However, its effectiveness and tolerability for COPD patients in routine clinical practice have not been well-investigated. This study aimed to assess the effectiveness of GLY on health-related quality of life and its safety in patients with COPD in a routine clinical care setting. This multi-center, prospective, six-month observational study recruited patients diagnosed with COPD and treated with GLY at three medical centers in central Taiwan. The full analysis set (n = 102) had a significant improvement in the Clinical COPD Questionnaire total (mean ± SD = −0.39 ± 0.90, p = 0.002), symptoms (mean ± SD = −0.61 ± 0.90, p < 0.001) and mental state scores (mean ± SD = −0.54 ± 1.72, p = 0.021) but not the functional state score (mean ± SD = −0.10 ± 1.15, p = 0.529). During the observational period, 58 patients (52.73%) experienced adverse events; only one adverse event (dizziness) was suspected to be related to the study drug. Three patients (2.73%) discontinued the study and GLY treatment because of an adverse event. One patient (0.91%) died during the study period because of a cerebral infarction, which was judged to be not associated with GLY treatment. In conclusion, GLY could be effective in improving the health status and is safe for patients with COPD in a real-life setting.
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Affiliation(s)
- Wei-Chang Huang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli 350, Taiwan
| | - Sheng-Hao Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 402, Taiwan
- Department of Recreation and Holistic Wellness, MingDao University, Changhua 523, Taiwan
| | - Liang-Wen Hang
- Sleep Medicine Center, Department of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: (L.-W.H.); (C.-H.L.); (J.-Y.H.)
| | - Ching-Hsiung Lin
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 402, Taiwan
- Department of Recreation and Holistic Wellness, MingDao University, Changhua 523, Taiwan
- Correspondence: (L.-W.H.); (C.-H.L.); (J.-Y.H.)
| | - Jeng-Yuan Hsu
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan
- School of Physical Therapy, Chung Shan Medical University, Taichung, 402, Taiwan
- Correspondence: (L.-W.H.); (C.-H.L.); (J.-Y.H.)
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Vogelmeier CF, Naya IP, Maltais F, Bjermer L, Kerwin EM, Tombs L, Jones PW, Compton C, Lipson DA, Boucot IH. Treatment of COPD with Long-Acting Bronchodilators: Association Between Early and Longer-Term Clinically Important Improvement. Int J Chron Obstruct Pulmon Dis 2021; 16:1215-1226. [PMID: 33976543 PMCID: PMC8106450 DOI: 10.2147/copd.s295835] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/22/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION This post hoc analysis of the "Early MAXimization of bronchodilation for improving COPD stability" (EMAX) trial investigated whether patients achieving early clinically important improvement (CII) sustained longer-term improvements and lower risk of clinically important deterioration (CID). METHODS Patients were randomized to umeclidinium/vilanterol, umeclidinium, or salmeterol for 24 weeks. The patient-reported outcomes (PROs) Transition Dyspnea Index (TDI), Evaluating Respiratory Symptoms, St George's Respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT) were assessed. CII, defined as attaining minimum clinically important differences (MCID) in ≥2 PROs, was assessed at Weeks 4, 12 and 24. CID was defined as a deterioration in CAT, SGRQ, TDI by the MCID and/or a moderate/severe exacerbation from Day 30. RESULTS Of 2425 patients, 50%, 53% and 51% achieved a CII at Weeks 4, 12 and 24, respectively. Patients with a CII at Week 4 versus those without had significantly greater odds of achieving a CII at Weeks 12 and 24 (odds ratio: 5.57 [95% CI: 4.66, 6.66]; 4.09 [95% CI: 3.44, 4.86]). The risk of a CID was higher in patients who did not achieve a CII at Week 4 compared with patients who did (hazard ratio [95% CI]: 2.09 [1.86, 2.34]). Patients treated with umeclidinium/vilanterol versus either monotherapy had significantly greater odds of achieving CII at Weeks 4, 12 and 24. CONCLUSION Achieving a CII at Week 4 was associated with longer-term improvement in PROs and a reduced risk of deterioration. Further research is required to investigate the importance of an early response to treatment on the long-term disease course.
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Affiliation(s)
- Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Ian P Naya
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
- RAMAX Ltd, Bramhall, Cheshire, UK
| | - François Maltais
- Centre De Pneumologie, Institut Universitaire De Cardiologie Et De Pneumologie De Québec, Université Laval, Québec, Canada
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Edward M Kerwin
- Altitude Clinical Consulting and Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Brentford, Middlesex, UK
| | - Paul W Jones
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Chris Compton
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - David A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Isabelle H Boucot
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
- Medical Emerging Markets, GSK, Brentford, Middlesex, UK
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Rabe KF, Halpin DMG, Han MK, Miravitlles M, Singh D, Grönke L, Voß F, Martinez FJ. Composite endpoints in COPD: clinically important deterioration in the UPLIFT trial. Respir Res 2020; 21:177. [PMID: 32646424 PMCID: PMC7350568 DOI: 10.1186/s12931-020-01431-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 06/21/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Assessments of lung function, exacerbations and health status are common measures of chronic obstructive pulmonary disease (COPD) progression and treatment response in clinical trials. We hypothesised that a composite endpoint could more holistically assess clinically important deterioration (CID) in a COPD clinical trial setting. METHODS A composite endpoint was tested in a post hoc analysis of 5652 patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2-4 COPD from the 4-year UPLIFT study. Patients received tiotropium 18 μg or placebo. RESULTS The composite endpoint included time to first confirmed decrease in trough forced expiratory volume in 1 s (FEV1) ≥100 mL, confirmed increase in St. George's Respiratory Questionnaire (SGRQ) total score ≥ 4 units, or moderate/severe exacerbation. Most patients (> 80%) experienced CID, with similar incidence among GOLD subgroups. Most confirmed trough FEV1 (74.6-81.6%) and SGRQ (72.3-78.1%) deteriorations were sustained across the study and in all GOLD subgroups. Patients with CID more frequently experienced subsequent exacerbation (hazard ratio [HR] 1.79; 95% confidence interval [CI] 1.67, 1.92) or death (HR 1.21; 95% CI 1.06, 1.39) by Month 6. CID was responsive to bronchodilator treatment. CONCLUSIONS Composite endpoints provide additional information on COPD progression and treatment effects in clinical trials. TRIAL REGISTRATION ClinicalTrials.gov NCT00144339 .
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Affiliation(s)
- Klaus F Rabe
- Member of the German Center for Lung Research (DZL), LungClinic Grosshansdorf, Wöhrendamm 80, 22927, Grosshansdorf, Germany.
- Member of the German Center for Lung Research (DZL), Christian Albrechts University Kiel, Kiel, Germany.
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Dave Singh
- Medicines Evaluation Unit (MEU), University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lars Grönke
- Clinical Development, CSL Behring GmbH, Marburg, Germany
| | - Florian Voß
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Fernando J Martinez
- Department of Internal Medicine, Weill Cornell School of Medicine, New York, NY, USA
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Singh D, Criner GJ, Naya I, Jones PW, Tombs L, Lipson DA, Han MK. Measuring disease activity in COPD: is clinically important deterioration the answer? Respir Res 2020; 21:134. [PMID: 32487202 PMCID: PMC7265253 DOI: 10.1186/s12931-020-01387-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
Given the heterogeneity of chronic obstructive pulmonary disease (COPD), personalized clinical management is key to optimizing patient outcomes. Important treatment goals include minimizing disease activity and preventing disease progression; however, quantification of these components remains a challenge. Growing evidence suggests that decline over time in forced expiratory volume in 1 s (FEV1), traditionally the key marker of disease progression, may not be sufficient to fully determine deterioration across COPD populations. In addition, there is a lack of evidence showing that currently available multidimensional COPD indexes improve clinical decision-making, treatment, or patient outcomes. The composite clinically important deterioration (CID) endpoint was developed to assess disease worsening by detecting early deteriorations in lung function (measured by FEV1), health status (assessed by the St George's Respiratory Questionnaire), and the presence of exacerbations. Post hoc and prospective analyses of clinical trial data have confirmed that the multidimensional composite CID endpoint better predicts poorer medium-term outcomes compared with any single CID component alone, and that it can demonstrate differences in treatment efficacy in short-term trials. Given the widely acknowledged need for an individualized holistic approach to COPD management, monitoring short-term CID has the potential to facilitate early identification of suboptimal treatment responses and patients at risk of increased disease progression. CID monitoring may lead to better-informed clinical management decisions and potentially improved prognosis.
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Affiliation(s)
- Dave Singh
- University of Manchester, Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Gerard J Criner
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Ian Naya
- GSK, Respiratory Medicines Development Centre, Stockley Park, Middlesex, UK
- RAMAX Ltd, Bramhall, Cheshire, UK
| | - Paul W Jones
- GSK, Respiratory Medicines Development Centre, Stockley Park, Middlesex, UK
| | | | - David A Lipson
- GSK, Respiratory Clinical Sciences, Collegeville, PA, USA
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
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Pharmacology, toxicology and clinical safety of glycopyrrolate. Toxicol Appl Pharmacol 2019; 370:154-169. [PMID: 30905688 DOI: 10.1016/j.taap.2019.03.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 02/03/2023]
Abstract
The clinical use of the anticholinergic glycopyrrolate dates back to the early 1960s when it was first approved in the U.S. Since then, oral and inhalation formulations have been developed as therapeutic agents inhibiting the muscarinic acetylcholine receptor in various indications including chronic obstructive pulmonary disease (COPD), excessive salivation, and peptic ulcers. More recently, topical formulations of glycopyrrolate (GPB, also known as glycopyrronium bromide) have gained interest as a treatment option for excessive sweating (hyperhidrosis). The U.S. Food and Drug Administration (FDA) approved the first topical glycopyrronium product for the treatment of hyperhidrosis in 2018. Glycopyrrolate, as a quaternary amine, shows minimal penetration of the blood brain barrier which limits CNS side effects. In addition, lack of phototoxicity, genotoxicity and carcinogenicity makes it suitable for chronic indications. The information on the nonclinical and clinical safety profile of glycopyrronium supporting various therapeutically approved uses has been obtained from published literature, our own data as well as summary documents issued by regulatory bodies. Collectively, these data support the conclusion that the benefits of glycopyrronium generally outweigh the risks in chronic use indications that require muscarinic receptor antagonism to provide therapeutic effects.
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Kupczyk M, Kuna P. Beclomethasone dipropionate, formoterol fumarate and glycopyrronium bromide as a combination therapy for chronic obstructive pulmonary disease. Expert Rev Respir Med 2018; 13:5-11. [PMID: 30463457 DOI: 10.1080/17476348.2019.1548937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The triple therapy term covers the combination of inhaled corticosteroid (ICS), long-acting β-receptor agonist (LABA) and long-acting anticholinergic drug (LAMA) in one or in separate inhalers. The latest GOLD 2018 (Global Initiative for Chronic Obstructive Disease) guidelines recommend the triple therapy in the management of chronic obstructive pulmonary disease (COPD) in patients of group D who despite the combination of two drugs: LAMA/LABA or ICS/LABA continue to have persistent symptoms or suffer from further frequent exacerbations. Areas covered: The first triple fixed-dose combination of extrafine beclomethasone/formoterol/glycopyrronium in one pMDI type inhaler intended for the treatment of COPD has been registered in Europe in 2017. Pharmacokinetic and pharmacodynamic properties, clinical efficacy and safety of this triple combination are presented in the review. Expert commentary: A 20% reduction in the risk of moderate or severe exacerbation was found in patients receiving triple therapy compared to the ICS/LABA combination and LAMA monotherapy. Triple therapy reduces the number of exacerbations in comparison with double bronchodilatation (LABA/LAMA), thus representing an interesting therapeutic option in the management of COPD. The profile of side effects of triple therapy is typical for individual active agents included in the combination.
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Affiliation(s)
- Maciej Kupczyk
- a Department of Internal Medicine, Asthma and Allergy , Medical University of Lodz , Lodz , Poland
| | - Piotr Kuna
- a Department of Internal Medicine, Asthma and Allergy , Medical University of Lodz , Lodz , Poland
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