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Papi A, Forini G, Maniscalco M, Bargagli E, Crimi C, Santus P, Molino A, Bandiera V, Baraldi F, D'Anna SE, Carone M, Marvisi M, Pelaia C, Scioscia G, Patella V, Aliani M, Fabbri LM. Inhaled corticosteroids in severe COPD patients with cardiovascular diseases. Authors' reply. Eur J Intern Med 2024:S0953-6205(24)00338-8. [PMID: 39117553 DOI: 10.1016/j.ejim.2024.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024]
Affiliation(s)
- Alberto Papi
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Respiratory Unit, CardioRespiratory Department, University Hospital Ferrara, Ferrara, Italy.
| | - Giacomo Forini
- Respiratory Unit, CardioRespiratory Department, University Hospital Ferrara, Ferrara, Italy
| | - Mauro Maniscalco
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese, Terme Institute, Telese, Italy; Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Elena Bargagli
- Department of Medical Sciences, Surgery and Neurosciences, Siena University, Siena, Italy
| | - Claudia Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Respiratory Medicine Unit, Policlinico "G. Rodolico-San Marco" University Hospital, Catania, Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy; Division of Respiratory Diseases, Ospedale Luigi Sacco-University Hospital, Milan, Italy
| | - Antonio Molino
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | | | - Federico Baraldi
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Respiratory Unit, CardioRespiratory Department, University Hospital Ferrara, Ferrara, Italy
| | - Silvestro Ennio D'Anna
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese, Terme Institute, Telese, Italy
| | - Mauro Carone
- Istituti Clinici Scientifici Maugeri, IRCCS, Pulmonology and Respiratory Rehabilitation Unit of Bari Institute, Bari, Italy
| | - Maurizio Marvisi
- Department of Internal Medicine, Istituto Figlie di S. Camillo, Cremona, Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Giulia Scioscia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Vincenzo Patella
- Department of Internal Medicine ASL Salerno, "Santa Maria della Speranza" Hospital, Salerno, Italy; Postgraduate Program in Allergy and Clinical Immunology, University of Naples "Federico II", Naples, Italy
| | - Maria Aliani
- Istituti Clinici Scientifici Maugeri, IRCCS, Pulmonology and Respiratory Rehabilitation Unit of Bari Institute, Bari, Italy
| | - Leonardo M Fabbri
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Brattsand R, Selroos O. May a different kinetic mode explain the high efficacy/safety profile of inhaled budesonide? Pulm Pharmacol Ther 2022; 77:102167. [PMID: 36180011 DOI: 10.1016/j.pupt.2022.102167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022]
Abstract
The claimed functional basis for ICSs in asthma and COPD is airway selectivity, attained by inhaling a potent, lipophilic compound with long local dissolution/absorption time. The development has been empirically based, resulting in five widely used ICSs. Among them, budesonide (BUD) deviates by being less lipophilic, leading to a more rapid systemic uptake with plasma peaks with some systemic anti-inflammatory activity. By this, BUD fits less well into the current pharmacological dogma of optimal ICS profile. In this review we compared the physicochemical, pharmacological and clinical properties of BUD, fluticasone propionate (FP) and fluticasone furoate (FF), representing different levels of lipophilicity, airway and systemic kinetics, focusing on their long-acting β2-agonist (LABA) combinations, in line with current GINA and GOLD recommendations. We are aware of the differences between formoterol (FORM) and the not rapid acting LABAs such as e.g. salmeterol and vilanterol but our comparisons are based on currently available combination products. A beclomethasone dipropionate (BDP)/FORM combination is also commented upon. Based on clinical comparisons in asthma and COPD, we conclude that the BUD/formoterol (BUD/FORM) combination is as effective and safe as the FP and FF combinations, and is in some cases even better as it can be used as "maintenance plus reliever therapy" (MART) in asthma and as maintenance in COPD. This is difficult to explain by current views of required ICS's/LABAs pharmacokinetic profiles. We propose that BUD achieves its efficacy by a combination of airway and systemic activity. The airway activity is dominating. The systemic activity contributes by plasma peaks, which are high enough for supportive anti-inflammatory actions at the blood and bone marrow levels but not sufficiently long to trigger a similar level of systemic adverse effects. This may be due to BUD's capacity to exploit a systemic differentiation mechanism as programmed for cortisol's various actions. This differentiation prospect can be reached only for an ICS with short plasma half-life. Here we present an alternative mode for an ICS to reach combined efficacy and safety, based on a poorly investigated and exploited physiological mechanism. A preference of this mode is broader versatility, due to that its straighter dose-response should allow a better adaptation to disease fluctuations, and that its rapid activity enables use as "anti-inflammatory reliever".
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Affiliation(s)
- Ralph Brattsand
- Experimental Pharmacology, Budera Company, Kristinehamn, Sweden.
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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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The Use of Inhaled Corticosteroids for Patients with COPD Who Continue to Smoke Cigarettes: An Evaluation of Current Practice. Am J Med 2022; 135:302-312. [PMID: 34655541 DOI: 10.1016/j.amjmed.2021.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022]
Abstract
The use of inhaled corticosteroids (ICS) in combination with inhaled bronchodilators for patients with chronic obstructive pulmonary disease (COPD) is a common practice in primary care settings. However, ICS-containing therapies may be less effective in patients with COPD compared with asthma, and in individuals with COPD who continue to smoke cigarettes. Preclinical studies suggest that inflammation in COPD is very different from in asthma. Glucocorticoid receptor functioning and other innate anti-inflammatory mechanisms are altered in cells exposed to cigarette smoke. COPD may be relatively insensitive to ICS, especially in individuals who continue to smoke. ICS-containing therapies in patients with asthma who continue to smoke may also be less effective compared with patients who do not smoke. ICS-containing therapies may be inappropriately used in some patients with COPD, and their long-term use is associated with an increased risk for side effects, including pneumonia and bone fractures in some patients. Treatment for patients with COPD should be carefully evaluated, and anti-inflammatory/bronchodilatory strategies should be chosen based on individual patient characteristics and recommendations in current guidelines.
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Lai CC, Chen CH, Chen KH, Wang CY, Huang TM, Wang YH, Wang HC. The Impact of 52-Week Single Inhaler Device Triple Therapy versus Dual Therapy on the Mortality of COPD Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Life (Basel) 2022; 12:life12020173. [PMID: 35207460 PMCID: PMC8877713 DOI: 10.3390/life12020173] [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: 11/27/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/28/2022] Open
Abstract
There are more single inhaler device triple therapy available for COPD patients now. However, the effect of long-term triple therapy fixed dose combination (FDC) on mortality remains unclear. This study aimed to evaluate the impact of one-year single inhaler device triple therapy, including long-acting β2-agonists (LABAs), long-acting muscarinic receptor antagonists (LAMAs), and inhaled corticosteroids (ICSs), with dual therapies, comprised of either LABA/LAMA or ICS/LABA, on the mortality of patients with COPD. We searched the PubMed, Cochrane library, Web of Science, Embase databases, and clinical trial registry of clinicaltrials.gov and WHO ICTRP. Randomized controlled trials (RCTs) compared single inhaler device triple and dual therapies for 52 weeks were selected for the meta-analysis. The primary endpoint was all-cause mortality. A total of 6 RCTs were selected for the meta-analysis, including 10,274 patients who received single inhaler device triple therapy (ICS/LABA/LAMA FDC) and 12,395 patients who received ICS/LABA or LABA/LAMA dual therapy. Risk of death was significantly lower in the ICS/LABA/LAMA FDC group compared to the LABA/LAMA group (RR = 0.69, 95% CI = 0.53–0.90, p = 0.007). There was no significant difference in mortality between the ICS/LABA/LAMA FDC and ICS/LABA therapy groups (RR = 0.94, 95% CI = 0.72–1.24, p = 0.66). In addition, patients receiving ICS/LABA/LAMA FDC therapy had less moderate or severe exacerbations compared with the dual therapy groups (RR = 0.76, 95% CI = 0.73–0.80, p < 0.001 for LABA/LAMA; RR = 0.84, 95% CI = 0.78–0.90, p < 0.001 for ICS/LABA). By contrast, the risk of pneumonia in the ICS/LABA/LAMA FDC group was higher than in the LABA/LAMA group (RR = 1.43, 95% CI = 1.21–1.68, p < 0.001). In conclusion, ICS/LABA/LAMA FDC therapy could help improve the clinical outcomes of patients with COPD. However, triple therapy could increase the risk of pneumonia in comparison with LABA/LAMA dual therapy.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan 710, Taiwan;
| | - Chao-Hsien Chen
- Division of Pulmonary, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan;
- Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan
| | - Kuang-Hung Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (K.-H.C.); (H.-C.W.)
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 231, Taiwan
- Correspondence: e-mail (C.-Y.W.); (T.-M.H.); (Y.-H.W.)
| | - Tsan-Ming Huang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 231, Taiwan
- Correspondence: e-mail (C.-Y.W.); (T.-M.H.); (Y.-H.W.)
| | - Ya-Hui Wang
- Medical Research Center, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 231, Taiwan
- Correspondence: e-mail (C.-Y.W.); (T.-M.H.); (Y.-H.W.)
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (K.-H.C.); (H.-C.W.)
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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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Lee YJ, Rhee CK, Hwang YI, Yoo KH, Lee SE, Lee D, Park YB, Kim Y. Escalation Time to Open Triple Combination Therapy from the Initiation of LAMA versus ICS/LABA in COPD Management: Findings from Comparing the Incidence of Tiotropium and ICS/LABA in Real-World Use in South Korea (CITRUS) Study. J Pers Med 2021; 11:jpm11121325. [PMID: 34945797 PMCID: PMC8703927 DOI: 10.3390/jpm11121325] [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: 10/18/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background: bronchodilators are the key treatment for chronic obstructive pulmonary disease (COPD), however, inhaled corticosteroids (ICSs)/long-acting β2-agonists (LABA) are widely prescribed. We compared the escalation time to open triple combination therapy between long-acting muscarinic receptor antagonists (LAMA) and ICS/LABA in COPD management. Methods: this retrospective study included COPD patients selected from the National Health Insurance Service of South Korea from January 2005 to April 2015. The primary outcome was the escalation time to triple therapy in patients who initially received LAMA or ICS/LABA. Other outcomes included risk factors predisposing escalation to triple combination therapy. Results: a total of 2444 patients were assigned to the LAMA or ICS/LABA groups. The incidences of triple combination therapy in the LAMA and ICS/LABA groups were 81.0 and 139.8 per 1000 person-years, respectively (p < 0.001); the median times to triple therapy escalation were 281 and 207 days, respectively (p = 0.03). Treatment with ICS/LABA showed a higher risk of triple therapy escalation compared to LAMA (hazard ratio (HR), 1.601; 95% confidence interval (CI), 1.402–1.829). The associated risk factor was male sex. (HR, 1.564; 95% CI, 1.352–1.809). Conclusions: the initiation of COPD treatment with LAMA is associated with a reduced escalation time to triple therapy compared with ICS/LABA.
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Affiliation(s)
- Ye Jin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea;
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Yong Il Hwang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang-si 14068, Korea;
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University Hospital, School of Medicine, Konkuk University, Seoul 05030, Korea;
| | - So Eun Lee
- Medical Affairs, Boehringer-Ingelheim Korea, Seoul 04527, Korea;
| | - Doik Lee
- Real-World Solutions, IQVIA, Seoul 05510, Korea;
| | - Yong Bum Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul 05355, Korea;
| | - Youlim Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University Hospital, School of Medicine, Konkuk University, Seoul 05030, Korea;
- Correspondence:
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Rogliani P, Calzetta L. Response to letter to the editor. Again on IMPACT: exacerbation after abrupt discontinuation of ICS and pneumonia in fluticasone furoate-containing FDCs. Expert Opin Pharmacother 2021; 22:943-945. [PMID: 33651655 DOI: 10.1080/14656566.2021.1898746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental 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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Barnes NC, Jones P, Lipson DA, Singh D, Martinez FJ. Letter to editor - a response to: 'efficacy and safety of triple combination therapy for treating chronic obstructive pulmonary disease: an expert review'. Expert Opin Pharmacother 2021; 22:939-941. [PMID: 33655817 DOI: 10.1080/14656566.2021.1898745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Neil C Barnes
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, UK.,William Harvey Institute, Bart's and the London School of Medicine and Dentistry, London, UK
| | - Paul Jones
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, UK.,Institute of Infection and Immunity, St George's, University of London, London, UK
| | - David A Lipson
- Clinical Sciences, GlaxoSmithKline, Collegeville, PA, USA.,Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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