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Miravitlles M, Acharya S, Aggarwal B, Fernandes FLA, Dreyse J, Jardim JR, Juthong S, Levy G, Sivori M. Clinical Concepts for Triple Therapy Use in Patients with COPD: A Delphi Consensus. Int J Chron Obstruct Pulmon Dis 2023; 18:1853-1866. [PMID: 37662490 PMCID: PMC10474219 DOI: 10.2147/copd.s424128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose Role of triple therapy in chronic obstructive pulmonary disease (COPD) management is supported by growing evidence, but consensus is lacking on various aspects. We conducted a Delphi survey in respiratory experts on the effects of triple therapy on exacerbation reduction, early optimization, pneumonia risk, and mortality benefits in COPD management. Methods The study comprised 2-round online surveys and a participant meeting with 21 respiratory experts from 10 countries. The 31-statement questionnaire was prepared using Decipher software after literature review. Responses were recorded using Likert scale ranging from 1 (disagreement) to 9 (agreement) with a consensus threshold of 75%. Results All experts participated in both surveys and 14/21 attended participant meeting. Consensus was reached on 13/31 questions in first survey and 4/14 in second survey on: mortality benefits of triple therapy; comparable pneumonia risk between single inhaler triple therapy (SITT) and multiple inhaler triple therapy (81%); preference of SITT for patients with high eosinophil count (95%); exacerbation risk reduction and healthcare cost benefits with early initiation of SITT post exacerbation-related hospitalization (<30 days) (86%). No consensus was reached on first line SITT use after first exacerbation resulting in COPD diagnosis (62%). Conclusion This study demonstrated that there is consensus among experts regarding many of the key concepts about appropriate clinical use and benefits of triple therapy in COPD. More evidence is required for evaluating the benefits of early optimisation of triple therapy.
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Affiliation(s)
- 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
| | | | | | - Frederico L A Fernandes
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jorge Dreyse
- Internal Medicine and Critical Care Center Departments, Clínica Las Condes and School of Medicine, Universidad Finis Terrae, Santiago, Chile
| | - José R Jardim
- Respiratory Division, Escola Paulista de Medicina, Federal University of São Paulo, Sao Paulo, Brazil
| | - Siwasak Juthong
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Gur Levy
- Emerging Markets, GlaxoSmithKline, Panama City, Panama
| | - Martin Sivori
- Pneumonology University Center, School of Medicine, University of Buenos Aires, Argentina, Unit of Pneumonology Hospital “Dr.J.M. Ramos Mejia”, Buenos Aires, Argentina
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Sethi S, Wright A, Hartgers-Gubbels ES, Hechtner M, Clark B, Wright C, Langham S, Buhl R. Costs and Clinical Consequences of Compliance with COPD GOLD Recommendations or National Guidelines Compared with Current Clinical Practice in Belgium, Germany, Sweden, and the United States. Int J Chron Obstruct Pulmon Dis 2022; 17:2149-2160. [PMID: 36101790 PMCID: PMC9464634 DOI: 10.2147/copd.s371440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose The objective of this study was to assess the clinical and cost benefits of treating patients with chronic obstructive pulmonary disease (COPD) according to global and national guidelines compared to real-life clinical practice in the United States and three European countries (Belgium, Germany, Sweden). Patients and Methods A cost-consequence model was developed to compare current prescribing patterns with two alternative scenarios, the first aligned with the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2022) recommendations and the second with national guidelines. Costs and clinical outcomes were modeled for these alternative scenarios over a time horizon of one year, based on real-world evidence and health insurance data. Results Current clinical practice in each of the countries was inconsistent with published recommendations. A redistribution to prescribing patterns according to global and national recommendations led to a substantial decrease in the use of inhaled corticosteroid (ICS) containing therapies of more than 80% and 44%, respectively. There was a reduced incidence of up to 16% of mild-to-moderate pneumonia and up to 29% of severe pneumonia. Exacerbations decreased across all countries apart from Sweden, where a small increase in the rate of exacerbations was due to the redistribution of some patients currently undergoing inhaled triple therapy to non-ICS-containing therapies. Adapting treatment to recommendations could provide potential cost savings of up to 13% in estimated annual direct costs, resulting predominantly from the reduction in cost of healthcare resource use, including hospitalization associated with treating incident pneumonia, particularly severe pneumonia. Cost savings for prevalent adult patients with COPD on long-acting inhaler therapy ranged from €31 to €675 per patient per year. Conclusion Redistribution of COPD patients from current clinical practice to treatment according to published recommendations would provide clinical benefits and substantial cost savings.
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Affiliation(s)
- Sanjay Sethi
- Pulmonary/Critical Care/Sleep Medicine, University at Buffalo, State University of New York, Buffalo, NY, USA
| | | | | | | | - Brendan Clark
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | | | - Sue Langham
- Maverex Ltd., Newcastle Upon Tyne, NE6 2HL, UK
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
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Jiang L, Kendzerska T, Aaron SD, Stukel TA, Stanbrook MB, Tan W, Pequeno P, Gershon AS. Prescription Pathways from Initial Medication Use to Triple Therapy in Older COPD Patients: A Real-World Population Study. COPD 2022; 19:315-323. [PMID: 35946353 DOI: 10.1080/15412555.2022.2087616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Triple therapy with an inhaled corticosteroid (ICS), a long-acting β2-agonist bronchodilator (LABA) and a long-acting muscarinic antagonist (LAMA) is recommended as step-up therapy for chronic obstructive pulmonary disease (COPD) patients who continue to have persistent symptoms and increased risk of exacerbation despite treatment with dual therapy. We sought to evaluate different treatment pathways through which COPD patients were escalated to triple therapy. METHODS We used population health databases from Ontario, Canada to identify individuals aged 66 or older with COPD who started triple therapy between 2014 and 2017. Median time from diagnosis to triple therapy was estimated using the Kaplan-Meier method. We classified treatment pathways based on treatments received prior to triple therapy and evaluated whether pathways differed by exacerbation history, blood eosinophil counts or time period. RESULTS Among 4108 COPD patients initiating triple therapy, only 41.2% had a COPD exacerbation in the year prior. The three most common pathways were triple therapy as initial treatment (32.5%), LAMA to triple therapy (29.8%), and ICS + LABA to triple therapy (15.4%). Median time from diagnosis to triple therapy was 362 days (95% confidence interval:331-393 days) overall, but 14 days (95% CI 12-17 days) in the triple therapy as initial treatment pathway. This pathway was least likely to contain patients with frequent or severe exacerbations (22.0% vs. 31.5%, p < 0.001) or with blood eosinophil counts ≥300 cells/µL (18.9% vs. 22.0%, p < 0.001). CONCLUSION Real-world prescription of triple therapy often does not follow COPD guidelines in terms of disease severity and prior treatments attempted.
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Affiliation(s)
- Lili Jiang
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ottawa, Ontario, Canada
| | - Tetyana Kendzerska
- ICES, Toronto, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ottawa, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Matthew B Stanbrook
- ICES, Toronto, Ottawa, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wan Tan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Andrea S Gershon
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ottawa, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Dhar R, Talwar D, Salvi S, Muralimohan BV, Panchal S, Patil S, Bhagat S, Khatri N, Barkate H. Use of single-inhaler triple therapy in the management of obstructive airway disease: Indian medical experts' review. ERJ Open Res 2022; 8:00556-2021. [PMID: 35350278 PMCID: PMC8958219 DOI: 10.1183/23120541.00556-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/07/2022] [Indexed: 11/05/2022] Open
Abstract
Obstructive airway disease (OAD), which includes COPD and asthma, is the leading cause of morbidity and mortality in India. Long-acting bronchodilators (long-acting β2 agonists (LABAs) and/or long-acting muscarinic antagonists (LAMAs)) and inhaled corticosteroids (ICS) have a vital role in the management of patients with OAD. While symptom burden and exacerbations are common amongst treated patients, poor adherence to inhaler therapy is a frequent challenge. Better treatment options that optimise symptom control, improve quality of life, reduce exacerbation risk and improve adherence are desired. Triple therapy (ICS/LABA/LAMA) is recommended in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021 guidelines for symptomatic COPD patients on ICS/LABA or LABA/LAMA, and who are at increased risk for frequent or severe exacerbations. Similarly, add-on LAMA is recommended in uncontrolled asthma patients on medium- to high-dose ICS/LABA by the Global Initiative for Asthma (GINA) 2021 guideline. In the real world, high-risk and overlapping phenotypes exist, which necessitate early initiation of triple therapy. We aim to provide an expert review on the use of single-inhaler triple therapy (SITT) for OAD management in global and Indian settings, knowledge from which can be extrapolated for appropriate treatment of Indian patients. The OAD population in India may benefit from early optimisation to SITT characterised by a high burden of exacerbating OAD, nonsmoker COPD and asthma-COPD overlap.
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Affiliation(s)
- Raja Dhar
- Dept of Pulmonology, The Calcutta Medical Research Institute, Kolkata, India
| | - Deepak Talwar
- Metro Respiratory Center, Pulmonology and Sleep Medicine, Metro Hospitals and Heart Institute, Noida, India
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - B V Muralimohan
- Dept of Internal Medicine and Pulmonology, Narayana Hrudayalaya - Mazumdar Shaw Medical Center, Bengaluru, India
| | - Sagar Panchal
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Saiprasad Patil
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Sagar Bhagat
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Nishtha Khatri
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Hanmant Barkate
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
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Characteristics and treatment patterns of patients with asthma on multiple-inhaler triple therapy in Spain. NPJ Prim Care Respir Med 2022; 32:11. [PMID: 35273167 PMCID: PMC8913688 DOI: 10.1038/s41533-022-00270-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/22/2021] [Indexed: 11/08/2022] Open
Abstract
The aim of this observational, retrospective study was to describe characteristics, treatment patterns, and adherence among patients with asthma who initiated multiple-inhaler triple therapy (MITT) in Catalonia, Spain. This study used data of patients initiating MITT in 2016 from the SIDIAP (Information System for Research in Primary Care) database, which covers ~80% of the Catalonian population (5.8 million). Of 1,204 patients initiating MITT, 361 (30.0%) stepped down (discontinued ≥ 1 and continued ≥1 MITT component) and 89 (7.4%) stopped all three components of MITT for a period of 60 days during the following 12 months. In the follow-up period, 196 (16.3%) patients were considered adherent to MITT (>0.8 proportion of days covered [PDC]), with a mean (standard deviation) PDC of 0.52 (0.51) days. Given the low adherence and substantial rates of step down/discontinuation among patients initiating MITT, there is an urgent need to implement strategies to improve treatment adherence/persistence.
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Cazzola M, Rogliani P, Laitano R, Calzetta L, Matera MG. Beyond Dual Bronchodilation – Triple Therapy, When and Why. Int J Chron Obstruct Pulmon Dis 2022; 17:165-180. [PMID: 35068929 PMCID: PMC8766250 DOI: 10.2147/copd.s345263] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Although pharmacological treatment of COPD is codified in different guidelines and strategy documents, there is abundant evidence of discrepancy between what they suggest and what health professionals prescribe, especially in low-risk groups where there is widespread overprescription of triple therapy. It is therefore necessary to clarify when the use of triple therapy is indicated in COPD patients and when it is preferable to maintain treatment with dual bronchodilation. In this article, we discuss our views based on our experience and what is reported in the literature and try to give answers to these two questions. The evidence generated by pivotal RCTs supports the use of triple therapy in patients who present for the first time and have severe airway obstruction, are symptomatic, have had frequent moderate or severe exacerbations in the previous year, and have peripheral eosinophilia. However, it is difficult to determine whether step-up is useful in all other cases because the available data are quite conflicting. It is likely that the inconsistency in the information generated by the various available studies may explain the prescribing behaviour of many physicians who do not adhere to recommendations of guidelines and strategies. However, it is necessary to establish whether and when the addition of an ICS to the LAMA/LABA combination is effective, to determine whether triple therapy can induce an additional clinical benefit over dual bronchodilation, irrespective of a preventive effect on COPD exacerbations, to establish its value, and to examine whether cost differences can support the use of triple therapy over combined LAMA/LABA therapy in real life.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
- Correspondence: Mario Cazzola Email
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Rossella Laitano
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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Miravitlles M, Roman-Rodríguez M, Ribera X, Ritz J, Izquierdo JL. Inhaled Corticosteroid Use Among COPD Patients in Primary Care in Spain. Int J Chron Obstruct Pulmon Dis 2022; 17:245-258. [PMID: 35115771 PMCID: PMC8800566 DOI: 10.2147/copd.s342220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Inhaled corticosteroids (ICS) are frequently used to treat chronic obstructive pulmonary disease (COPD) outside the current recommendations. Our aim was to describe ICS use in COPD patients and to identify factors associated with ICS use among COPD patients treated within primary care in Spain. Patients and Methods This was a cross-sectional, non-interventional and multicenter study of patients with COPD treated in primary care. Patient characteristics and exacerbations were described in terms of ICS use among the overall cohort, and among those with spirometry confirmed COPD (post-bronchodilator forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ratio <70%). Multivariable logistic regression was used to identify factors associated with ICS use. Results A total of 901 patients were included, of which 47.9% (n = 432) were treated with ICS. A total of 240 patients (26.6%) experienced moderate/severe exacerbations in the prior year, while 309 (34.3%) during the previous two years. History of asthma totaled 11.6% (n = 105). The most frequent phenotype was non-exacerbator (51.6%), and the proportion of patient with moderate or severe exacerbations was significantly higher among ICS treated patients compared to non-treated: 37.5% versus 16.6% during the previous year (p < 0.001), and 46.8% versus 22.8% during the previous 2-years (p < 0.001), respectively. Patient characteristics were similar among spirometry confirmed patients and the overall population. Factors significantly associated with ICS use were a history of asthma (OR = 4.39, 95% CI: 2.67–7.26), the presence of moderate or severe exacerbations in the last year (OR = 2.52, 95% CI: 1.81–3.49), followed by higher mMRC and higher CAT score. Conclusion Nearly half of patients in primary care in Spain are treated with ICS, despite most of them being non-exacerbators. History of asthma, exacerbations, and worse dyspnea and CAT scores are associated with ICS use.
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Affiliation(s)
- 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
- Correspondence: Marc Miravitlles, Pneumology Department, Hospital Universitari Vall d’Hebron, P. Vall d’Hebron 119-129, Barcelona, ES–08035, Spain, Email
| | - Miguel Roman-Rodríguez
- Centro de Salud Dra. Teresa Pique, Mallorca, Spain
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Mallorca, Spain
| | - Xavier Ribera
- Boehringer Ingelheim España, Sant Cugat del Vallés, Barcelona, Spain
| | - John Ritz
- Syneos Health - Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - José Luis Izquierdo
- Department of Medicine and Medical Specialties, Universidad de Alcalá, Madrid, Spain
- Pneumology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
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