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Solidoro P, Dente F, Micheletto C, Pappagallo G, Pelaia G, Papi A. An Italian Delphi Consensus on the Triple inhalation Therapy in Chronic Obstructive Pulmonary Disease. Multidiscip Respir Med 2024; 19. [PMID: 39291458 DOI: 10.5826/mrm.2024.949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/01/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND The management of chronic obstructive pulmonary disease (COPD) lacks standardization due to the diverse clinical presentation, comorbidities, and limited acceptance of recommended approaches by physicians. To address this, a multicenter study was conducted among Italian respiratory physicians to assess consensus on COPD management and pharmacological treatment. METHODS The study employed the Delphi process using the Estimate-Talk-Estimate method, involving a scientific board and expert panel. During a 6-month period, the scientific board conducted the first Delphi round and identified 11 broad areas of COPD management to be evaluated while the second Delphi round translated all 11 items into statements. The statements were subsequently presented to the expert panel for independent rating on a nine-point scale. Consensus was considered achieved if the median score was 7 or higher. Consistently high levels of consensus were observed in the first rating, allowing the scientific board to finalize the statements without requiring further rounds. RESULTS Topics generating substantial discussion included the pre-COPD phase, patient-reported outcomes, direct escalation from a single bronchodilator to triple therapy, and the role of adverse events, particularly pneumonia, in guiding triple therapy prescriptions. Notably, these topics exhibited higher standard deviations, indicating greater variation in expert opinions. CONCLUSIONS The study emphasized the significance that Italian pulmonologists attribute to managing mortality, tailoring treatments, and addressing cardiovascular comorbidities in COPD patients. While unanimous consensus was not achieved for all statements, the results provide valuable insights to inform clinical decision-making among physicians and contribute to a better understanding of COPD management practices in Italy.
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Affiliation(s)
- Paolo Solidoro
- University of Turin, Medical Sciences Department, Pneumology Unit U, Cardiovascular and Thoracic Department, AOU Città Della Salute e Della Scienza di Torino, Italy
| | - Federico Dente
- Respiratory Pathophysiology Unit, Department of Surgery, Medicine, Molecular Biology, and Critical Care, University of Pisa, Pisa, Italy
| | - Claudio Micheletto
- Pneumology Unit, Cardio-Thoracic Department, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giovanni Pappagallo
- School of Clinical Methodology, IRCCS "Sacre Heart - Don Calabria", Negrar di Valpolicella, Italy
| | - Girolamo Pelaia
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | - Alberto Papi
- Respiratory Medicine Unit, University of Ferrara, Ferrara, Italy
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Farrell LA, O’Rourke MB, Padula MP, Souza-Fonseca-Guimaraes F, Caramori G, Wark PAB, Dharmage SC, Hansbro PM. The Current Molecular and Cellular Landscape of Chronic Obstructive Pulmonary Disease (COPD): A Review of Therapies and Efforts towards Personalized Treatment. Proteomes 2024; 12:23. [PMID: 39189263 PMCID: PMC11348234 DOI: 10.3390/proteomes12030023] [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: 05/28/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 08/28/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) ranks as the third leading cause of global illness and mortality. It is commonly triggered by exposure to respiratory irritants like cigarette smoke or biofuel pollutants. This multifaceted condition manifests through an array of symptoms and lung irregularities, characterized by chronic inflammation and reduced lung function. Present therapies primarily rely on maintenance medications to alleviate symptoms, but fall short in impeding disease advancement. COPD's diverse nature, influenced by various phenotypes, complicates diagnosis, necessitating precise molecular characterization. Omics-driven methodologies, including biomarker identification and therapeutic target exploration, offer a promising avenue for addressing COPD's complexity. This analysis underscores the critical necessity of improving molecular profiling to deepen our comprehension of COPD and identify potential therapeutic targets. Moreover, it advocates for tailoring treatment strategies to individual phenotypes. Through comprehensive exploration-based molecular characterization and the adoption of personalized methodologies, innovative treatments may emerge that are capable of altering the trajectory of COPD, instilling optimism for efficacious disease-modifying interventions.
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Affiliation(s)
- Luke A. Farrell
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Centre for Inflammation, Ultimo, NSW 2007, Australia;
| | - Matthew B. O’Rourke
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Centre for Inflammation, Ultimo, NSW 2007, Australia;
| | - Matthew P. Padula
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Ultimo, NSW 2007, Australia;
| | | | - Gaetano Caramori
- Pulmonology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Peter A. B. Wark
- School of Translational Medicine, Monash University, Melbourne, VIC 3000, Australia;
| | - Shymali C. Dharmage
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - Phillip M. Hansbro
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Centre for Inflammation, Ultimo, NSW 2007, Australia;
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Luo Q, Sun M, Xu G, Tian H, Yang C, Huang L, Li X, Wang Z, Lu G, Yang Z, Ji L, Liang F. Exploration of quantitative-effectiveness association between acupuncture temporal parameters and stable chronic obstructive pulmonary disease: A systematic review and dose-response meta-analysis of randomized controlled trials. Complement Ther Med 2024; 82:103048. [PMID: 38734186 DOI: 10.1016/j.ctim.2024.103048] [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: 09/13/2023] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is a globally common chronic respiratory disease with a high morbidity and mortality rate. Acupuncture has been proven effective for COPD. A dose-response meta-analysis was conducted to assess the correlation between the acupuncture temporal parameters(session, frequency, and duration) and its effectiveness in patients with stable COPD. METHODS Acupuncture randomized controlled trials on COPD were searched in eight databases from their inception to June 2023. The "doses" were defined as the acupuncture session, frequency, and duration. The outcomes mainly included Forced Expiratory Volume in one-second rate (FEV1%) and Six-minute Walking Distance (6MWD). The assessment of bias risk and literature quality were conducted independently using the Cochrane risk of bias tool and the Standards for reporting interventions in clinical trials of acupuncture. The dose-response relationship was modeled using robust error element regression, and meta-analysis was operated by R 4.3.1 and Stata 15.0. The protocol was registered in PROSPERO with the registration number CRD42023401406. RESULT Out of 1669 records, 17 RCTs with 1165 participants were finally included in the meta-analysis. There was notable heterogeneity among the studies, but sensitivity analysis demonstrated good robustness. The findings revealed a significant improvement in the following outcomes for stable COPD patients in the acupuncture group: FEV1% (MD=3.50, 95%CI: 2.05-4.95), 6MWD (MD=47.39, 95%CI: 29.29-65.50), St. George's respiratory questionnaire (SGRQ; MD=-8.25, 95%CI: -11.38 to -5.12); COPD assessment test (CAT; MD=-2.91, 95%CI: -3.99 to -1.83). The relationship between the acupuncture session, duration, and FEV1%, 6MWD followed a "Λ" curve pattern, while the relationship between acupuncture frequency and FEV1%, 6MWD exhibited logarithmic growth. Firstly, After 12 acupuncture sessions, FEV1% and 6MWD increased by 7.06% (95%CI: 4.56-9.55) and 36.28 m (95%CI: 20.37-52.20), respectively. The peak improvement in FEV1% and 6MWD was observed after 18 acupuncture sessions (MD=7.89, 95% CI: 5.33-10.45) and 45 sessions (MD=125.43, 95% CI: 72.80-178.07) each. Additionally, weekly acupuncture resulted in a 4.14% improvement in FEV1% (95% CI: 2.55-5.72) and a 42.49 m increase in 6MWD (95%CI: 17.16-67.81). Notably, the maximum effects on FEV1% and 6MWD improvement were achieved with different acupuncture frequencies, specifically three times a week (MD=6.00, 95% CI: 5.34-6.66) and once a day(MD=112.41, 95% CI: 77.27-147.56), respectively. Furthermore, after a 28-day duration of acupuncture treatment, FEV1% increased by 4.74% (95% CI: 3.73-5.75) and 6MWD increased by 47.34 m (95%CI: 22.01-72.67). During 60 days of acupuncture treatment, the FEV1% and 6MWD improvement reached their highest levels at 8.76% (95% CI: 7.05-10.47) and 88.06 m (95% CI: 45.96-130.16), respectively. CONCLUSION Acupuncture was effective in improving FEV1%, 6MWD, SGRQ, and CAT in patients with stable COPD. There was a dose-response relationship between the time parameters of acupuncture (session, frequency, and duration) and the efficacy of COPD treatment (FEV1% and 6MWD). The minimal clinically important difference could be achieved after 12 acupuncture sessions. Acupuncture with a medium-frequency (2-3 times per week) over 60 days may result in the greatest improvement in FEV1%, while higher-frequency acupuncture (5-7 times per week) for 2 months may lead to the maximum improvements in 6MWD. It indicated that the optimal acupuncture duration for different indicators remains consistent, while the optimal frequencies may differ. To confirm these results, it is necessary to conduct multicenter, large-scale randomized controlled trials. ETHICS AND DISSEMINATION Ethical approval is not required for literature-based studies. The results will be published in peer-reviewed journals or conferences.
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Affiliation(s)
- Qin Luo
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China
| | - Mingsheng Sun
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China; Sichuan Clinical Research Center of Acupuncture and Moxibustion, Chengdu, China
| | - Guixing Xu
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China
| | - Hao Tian
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China
| | - Chunyan Yang
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China
| | - Liuyang Huang
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China
| | - Xi Li
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China
| | - Ziwen Wang
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China
| | - Guangbing Lu
- Department of Respiratory and Critical Care Medicine, Meishan Hospital of Chinese Medicine, Meishan, China
| | - Zuoqin Yang
- Department of acupuncture and moxibustion, Pidu District Hospital of Traditional Chinese Medicine, Chengdu, China
| | - Laixi Ji
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China; School of Acupuncture and Moxibustion, Shanxi University of Chinese Medicine, Taiyuan, China.
| | - Fanrong Liang
- School of Acupuncture and Moxibustion, Chengdu University of Chinese Medicine, Chengdu, China.
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Klitgaard A, Ibsen R, Lykkegaard J, Hilberg O, Løkke A. National Development in the Use of Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease: Repeated Cross-Sectional Studies from 1998 to 2018. Biomedicines 2024; 12:372. [PMID: 38397973 PMCID: PMC10886715 DOI: 10.3390/biomedicines12020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Recommendations for the treatment of chronic obstructive pulmonary disease (COPD) have shifted towards a more restrictive use of inhaled corticosteroids (ICS). We aimed to identify the nationwide development over time in the use of ICS treatment in COPD. We conducted a register-based repeated cross-sectional study using Danish nationwide registers. On a yearly basis from 1998 to 2018, we included all patients in Denmark ≥ 40 years of age with an ICD-10 diagnosis of COPD (J44). Accumulated ICS use was calculated for each year based on redeemed prescriptions. Patients were divided into the following groups: No ICS, low-dose ICS, medium-dose ICS, or high-dose ICS. From 1998 to 2018, the yearly proportion of patients without ICS treatment increased (from 50.6% to 57.6%), the proportion of patients on low-dose ICS treatment increased (from 11.3% to 14.9%), and the proportion of patients on high-dose ICS treatment decreased (from 17.0% to 9.4%). We demonstrated a national reduction in the use of ICS treatment in COPD from 1998 to 2018, with an increase in the proportion of patients without ICS and on low-dose ICS treatment and a decrease in the proportion of patients on high-dose ICS treatment.
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Affiliation(s)
- Allan Klitgaard
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | | | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 6705 Esbjerg, Denmark;
| | - Ole Hilberg
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | - Anders Løkke
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
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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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Quint JK, Ariel A, Barnes PJ. Rational use of inhaled corticosteroids for the treatment of COPD. NPJ Prim Care Respir Med 2023; 33:27. [PMID: 37488104 PMCID: PMC10366209 DOI: 10.1038/s41533-023-00347-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/04/2023] [Indexed: 07/26/2023] Open
Abstract
Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.
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Affiliation(s)
- Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK.
| | - Amnon Ariel
- Lung Unit, Emek Medical Center, Afula, Israel
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
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7
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Miravitlles M, Matsunaga K, Dreher M. Stepwise management of COPD: What is next after bronchodilation? Ther Adv Respir Dis 2023; 17:17534666231208630. [PMID: 37936381 PMCID: PMC10631322 DOI: 10.1177/17534666231208630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, University Hospital Vall d′Hebron/Vall d’Hebron Research Institute (VHIR, Vall d’Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias [CIBERES]), P. Vall d’Hebron 119–129, Barcelona 08035, Spain
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
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Jones AW, McKenzie JE, Osadnik CR, Stovold E, Cox NS, Burge AT, Lahham A, Lee JYT, Hoffman M, Holland AE. Non-pharmacological interventions for the prevention of hospitalisations in stable chronic obstructive pulmonary disease: component network meta-analysis. Hippokratia 2022. [DOI: 10.1002/14651858.cd015153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Arwel W Jones
- Respiratory Research@Alfred, Department of Immunology and Pathology; Monash University; Melbourne Australia
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | | | - Elizabeth Stovold
- Population Health Research Institute; St George's, University of London; London UK
| | - Narelle S Cox
- Respiratory Research@Alfred, Department of Immunology and Pathology; Monash University; Melbourne Australia
- Institute for Breathing and Sleep; Melbourne Australia
| | - Angela T Burge
- Respiratory Research@Alfred, Department of Immunology and Pathology; Monash University; Melbourne Australia
- Institute for Breathing and Sleep; Melbourne Australia
- Department of Physiotherapy; Alfred Health; Melbourne Australia
| | - Aroub Lahham
- Respiratory Research@Alfred, Department of Immunology and Pathology; Monash University; Melbourne Australia
| | - Joanna YT Lee
- Respiratory Research@Alfred, Department of Immunology and Pathology; Monash University; Melbourne Australia
| | - Mariana Hoffman
- Respiratory Research@Alfred, Department of Immunology and Pathology; Monash University; Melbourne Australia
| | - Anne E Holland
- Respiratory Research@Alfred, Department of Immunology and Pathology; Monash University; Melbourne Australia
- Institute for Breathing and Sleep; Melbourne Australia
- Department of Physiotherapy; Alfred Health; Melbourne Australia
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Miravitlles M, Verhamme K, Calverley PMA, Dreher M, Bayer V, Gardev A, de la Hoz A, Wedzicha J, Price D. A Pooled Analysis of Mortality in Patients with COPD Receiving Dual Bronchodilation with and without Additional Inhaled Corticosteroid. Int J Chron Obstruct Pulmon Dis 2022; 17:545-558. [PMID: 35309285 PMCID: PMC8924530 DOI: 10.2147/copd.s350167] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/21/2022] [Indexed: 12/30/2022] Open
Abstract
Background Recent studies report a lower mortality rate during treatment with long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) versus LAMA/LABA in patients with symptomatic chronic obstructive pulmonary disease (COPD) and a history of exacerbations. Objective We compared time to all-cause mortality with LAMA/LABA versus LAMA/LABA/ICS in patients with mild-to-very-severe COPD and a predominantly low exacerbation risk. Methods Data were pooled from six randomized controlled trials (TONADO 1/2, DYNAGITO, WISDOM, UPLIFT and TIOSPIR; LAMA/LABA: n = 3156, LAMA/LABA/ICS: n = 11,891). Analysis was on-treatment and data were censored at 52 weeks. Patients on LAMA/LABA/ICS received ICS prior to study entry, which was not withdrawn at randomization. Patients on LAMA/LABA/ICS were propensity score (PS)-matched to patients on LAMA/LABA who had not previously received ICS; covariates included age, sex, geographical region, smoking status, post-bronchodilator forced expiratory volume in 1 second percent predicted, exacerbation history in previous year, body mass index and time since diagnosis. Time to all-cause mortality was assessed using Cox proportional hazard regression models. Results After PS matching, 3133 patients on LAMA/LABA and 3133 patients on LAMA/LABA/ICS were analyzed. Fewer than 20% of patients reported ≥2 exacerbations in the prior year (LAMA/LABA: 19.1%; LAMA/LABA/ICS: 19.0%). There were 41 (1.3%) deaths on LAMA/LABA and 45 (1.4%) deaths on LAMA/LABA/ICS. No statistically significant difference in time to death was observed between treatment arms (hazard ratio for LAMA/LABA 1.06; 95% confidence intervals 0.68, 1.64; P = 0.806). Sensitivity analyses conducted using different covariates or in an intent-to-treat population showed similar results. Conclusion This pooled analysis of over 6000 patients with mild-to-very-severe COPD and predominantly low exacerbation risk showed no differences in mortality with LAMA/LABA versus LAMA/LABA/ICS, suggesting that the survival benefit of triple therapy seen in some recent studies may be specific to a high-risk population. This supports current Global Initiative for Chronic Obstructive Lung Disease recommendations that triple therapy should be reserved for the subpopulations of patients who need it the most (eg, those with an eosinophilic phenotype and a high risk of exacerbations) to avoid ICS overuse.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Katia Verhamme
- Department of Medical Informatics, Erasmus MC, Rotterdam, the Netherlands
| | - Peter M A Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
| | - Valentina Bayer
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Jadwiga Wedzicha
- Head Respiratory Division, National Heart and Lung Institute, Imperial College London, London, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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10
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Sriram K, Insel MB, Insel PA. Inhaled β2 Adrenergic Agonists and Other cAMP-Elevating Agents: Therapeutics for Alveolar Injury and Acute Respiratory Disease Syndrome? Pharmacol Rev 2021; 73:488-526. [PMID: 34795026 DOI: 10.1124/pharmrev.121.000356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/15/2021] [Indexed: 12/15/2022] Open
Abstract
Inhaled long-acting β-adrenergic agonists (LABAs) and short-acting β-adrenergic agonists are approved for the treatment of obstructive lung disease via actions mediated by β2 adrenergic receptors (β2-ARs) that increase cellular cAMP synthesis. This review discusses the potential of β2-AR agonists, in particular LABAs, for the treatment of acute respiratory distress syndrome (ARDS). We emphasize ARDS induced by pneumonia and focus on the pathobiology of ARDS and actions of LABAs and cAMP on pulmonary and immune cell types. β2-AR agonists/cAMP have beneficial actions that include protection of epithelial and endothelial cells from injury, restoration of alveolar fluid clearance, and reduction of fibrotic remodeling. β2-AR agonists/cAMP also exert anti-inflammatory effects on the immune system by actions on several types of immune cells. Early administration is likely critical for optimizing efficacy of LABAs or other cAMP-elevating agents, such as agonists of other Gs-coupled G protein-coupled receptors or cyclic nucleotide phosphodiesterase inhibitors. Clinical studies that target lung injury early, prior to development of ARDS, are thus needed to further assess the use of inhaled LABAs, perhaps combined with inhaled corticosteroids and/or long-acting muscarinic cholinergic antagonists. Such agents may provide a multipronged, repurposing, and efficacious therapeutic approach while minimizing systemic toxicity. SIGNIFICANCE STATEMENT: Acute respiratory distress syndrome (ARDS) after pulmonary alveolar injury (e.g., certain viral infections) is associated with ∼40% mortality and in need of new therapeutic approaches. This review summarizes the pathobiology of ARDS, focusing on contributions of pulmonary and immune cell types and potentially beneficial actions of β2 adrenergic receptors and cAMP. Early administration of inhaled β2 adrenergic agonists and perhaps other cAMP-elevating agents after alveolar injury may be a prophylactic approach to prevent development of ARDS.
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Affiliation(s)
- Krishna Sriram
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
| | - Michael B Insel
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
| | - Paul A Insel
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
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Alcázar-Navarrete B, García-Rio F, Sánchez G, Mariscal E, García A, Cuesta M, Uría E, Miravitlles M. Burden of Disease Among Exacerbating Patients with COPD Treated with Triple Therapy in Spain. Int J Chron Obstruct Pulmon Dis 2021; 16:2149-2161. [PMID: 34321874 PMCID: PMC8312318 DOI: 10.2147/copd.s310319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/19/2021] [Indexed: 12/28/2022] Open
Abstract
Background The cost of chronic obstructive pulmonary disease (COPD) in Spain has been studied from different perspectives, but parameters such as the patient's phenotype have seldom been considered. Our aim was to describe the disease burden of COPD patients with frequent exacerbator phenotype, treated with triple therapy. Methods An observational, multicenter study was carried out from December 2017 to November 2018 in pulmonology services among patients ≥40 years with COPD confirmed diagnosis receiving triple therapy (ICS/LAMA/LABA) and history of ≥2 moderate or ≥1 severe exacerbation in the 12 months prior to the inclusion visit. COPD-related healthcare resources were collected over a 12-months period prior to the inclusion visit: pharmacological and non-pharmacological treatments, medical and ER visits, hospitalizations, tests and productivity loss. Costs were updated to €2019. Patients were classified according to blood eosinophil levels: <150 cells/µL and ≥150 cells/µL. Results A total of 306 patients were included (77.1% men), with mean age of 69.9 years. Mean COPD exacerbation rate was 2.5/patient/year and 51.3% of patients had ≥150 cells/µL eosinophil level. On average, for the total population, COPD-related visits/patients/year were 6.2. Resource use in moderate exacerbation was higher in patients with eosinophils ≥150 cells/µL, whereas in severe exacerbation was higher in patients with eosinophils <150cells/µL. According to eosinophil levels, total annual mean (SD) costs/patient accounted for €8382 (9863) and €5144 (5444) for patients with eosinophils <150 cells/µL and ≥150 cells/µL, respectively. Conclusion The impact of exacerbating COPD patients treated with triple therapy in Spain is large, especially among those with eosinophils <150 cells/µL.
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Affiliation(s)
- Bernardino Alcázar-Navarrete
- Respiratory Department. Hospital Universitario Virgen de las Nieves, Granada, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Francisco García-Rio
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | | | | | | | | | | | - Marc Miravitlles
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Pneumology Department, Hospital Universitari Vall d’Hebron, Vall D’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
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12
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Monteagudo M, Barrecheguren M, Solntseva I, Dhalwani N, Booth A, Nuñez A, Lambrelli D, Miravitlles M. Clinical characteristics and factors associated with triple therapy use in newly diagnosed patients with COPD. NPJ Prim Care Respir Med 2021; 31:16. [PMID: 33753747 PMCID: PMC7985144 DOI: 10.1038/s41533-021-00227-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/03/2021] [Indexed: 12/18/2022] Open
Abstract
There is limited information about the initiation of triple therapy (TT) in patients with chronic obstructive pulmonary disease (COPD) in primary care. This was an observational, population-based study in patients identified from a primary care electronic medical records database in Catalonia from 2011 to 2015 aimed to identify the use of TT in patients with newly diagnosed COPD. A total of 69,668 newly diagnosed patients were identified of whom 11,524 (16.5%) initiated TT, of whom 8626 initiated TT at or immediately after COPD diagnosis. Among them, 72.3% were GOLD A/B, 14.6% were frequent exacerbators, and 7.1% had asthma-COPD overlap (ACO). Variables associated with TT initiation were: male sex, older age, previous exacerbations, ACO, a previous treatment regimen containing an inhaled corticosteroid, previous pneumonia, and history of lung cancer. A significant number of COPD patients in Primary Care initiated TT shortly after or even before an established COPD diagnosis.
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Affiliation(s)
- Mònica Monteagudo
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Miriam Barrecheguren
- 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
| | - Iryna Solntseva
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | | | | | - Alexa Nuñez
- Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- 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
| | | | - Marc Miravitlles
- Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
- 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.
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13
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Monteagudo M, Nuñez A, Solntseva I, Dhalwani N, Booth A, Barrecheguren M, Lambrelli D, Miravitlles M. Treatment Pathways Before and After Triple Therapy in COPD: A Population-based Study in Primary Care in Spain. Arch Bronconeumol 2020; 57:205-213. [PMID: 33004238 DOI: 10.1016/j.arbres.2020.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recent data from real world clinical practices on the use of Triple Therapy (TT) in patients with COPD are scarce. METHODS Observational population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical records database in Catalonia, covering 80% of the general population. The aims were to characterize COPD patients who initiated TT and to describe treatment pathways before and after TT initiation. Time to and probability of step down or complete discontinuation of TT was described using restricted mean survival time and Kaplan-Meier analysis. RESULTS A total of 34,018 COPD patients initiated TT during the study period. Of them, 23,867 (70.1%) were GOLD A/B. 18,453 (54.2%) were non-exacerbators, 9931 (29.2%) infrequent exacerbators, 5634 (16.5%) frequent exacerbators and 1923 (5.6%) had asthma-COPD overlap. Drugs most frequently used prior to initiation of TT were long-acting antimuscarinics (22.5%) and combination of long-acting beta2 agonists/inhaled corticosteroids (15.2%). A total of 11,666 (34.3%) stepped down and 1091 (3.2%) discontinued TT during follow-up. Step down following TT was more likely in patients with severe COPD, especially during the first year; however, discontinuation was more common among patients with mild COPD. CONCLUSION Most patients initiating treatment with TT were non exacerbators and continued on the same treatment over time regardless severity of disease. Stepping down was more frequent in severe patients, while discontinuation was more common among mild patients. Overall, it appears that TT is extensively used in primary care for treatment of patients with COPD.
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Affiliation(s)
- Mònica Monteagudo
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Alexa Nuñez
- Pneumology Department, Hospital Universitari Vall d́Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Medicine Department, Autonomous University of Barcelona (UAB), Bellaterra (Cerdanyola del Vallés), Barcelona, Spain
| | - Iryna Solntseva
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | | | - Alison Booth
- Medicine Department, Autonomous University of Barcelona (UAB), Bellaterra (Cerdanyola del Vallés), Barcelona, Spain; Evidera, London, UK
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d́Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d́Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Medicine Department, Autonomous University of Barcelona (UAB), Bellaterra (Cerdanyola del Vallés), Barcelona, Spain.
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Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a heterogeneous syndrome and may comprise several different phenotypes that are driven by different molecular mechanisms (endotypes). Several different clinical, genetic, and inflammatory phenotypes of COPD have been recognized and this may lead to more precise effective therapies. AREAS COVERED The different clinical phenotypes, including smoking versus nonsmoking COPD, small airway disease versus emphysema, non-exacerbators versus frequent exacerbators are discussed. Rare genetic endotypes (alpha1-antitrypsin deficiency, telomerase polymorphisms), and inflammatory phenotypes (eosinophilic versus neutrophilic) are also recognized in stable and exacerbating patients and have implications for the choice of therapy. EXPERT OPINION Clinical phenotypes have so far not proved to be very useful in selecting more personalized therapy for COPD. Even with genetic endotypes, this has not led to improved therapy. More promising is the recognition that COPD patients who have increased sputum or blood eosinophils tend to have more frequent exacerbations and inhaled corticosteroids are more effective in preventing exacerbation. Increased blood eosinophils have proved to be a useful biomarker now used to target ICS more effectively. Furthermore, COPD patients with low eosinophils are more likely to get pneumonia with ICS and to have lower airway bacterial colonization.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College London , London, UK
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15
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Treatment of COPD and COPD-heart failure comorbidity in primary care in different stages of the disease. Prim Health Care Res Dev 2020; 21:e16. [PMID: 32498750 PMCID: PMC7303800 DOI: 10.1017/s1463423620000079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that may have a negative impact on both patients’ quality of life and survival. Patients with COPD frequently suffer from heart failure (HF), likely owing to several shared risk factors. Aim: To evaluate the differences in treatment of COPD with and without HF comorbidity according to COPD severity in the general practitioner setting. Methods: We conducted an observational, retrospective study using data obtained from the Italian Health Search Database, which collects information generated by the routine activity of general practitioners. The study sample included 225 patients with COPD, alone or combined with HF. Findings: It has been found that the prevalence of some comorbidities such as diabetes and HF significantly increases with the severity of COPD. Regarding pharmacological treatment, a reduction in the prescription of individually administered long-acting β 2-agonists (LABAs) and long-acting anticholinergics (LAMAs) has been observed with increasing severity of the disease. Moreover, an increase in the prescription of both the combination of the two bronchodilators (LABA + LAMA) and their association with inhaled corticosteroids has been observed with increasing severity of COPD. The prescription of β-blockers in patients with COPD suffering from HF comorbidity decreases from 100% in stage I to less than 50% in the other stages of COPD. This study shows that general practitioners do not follow the guidelines recommendations for the management of patients with COPD in the different stages of the disease, with and without HF comorbidity, as well as in the management of HF. Further efforts must be made to ensure adequate treatment for these patients.
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Stolz D, Miravitlles M. The right treatment for the right patient with COPD: lessons from the IMPACT trial. Eur Respir J 2020; 55:55/5/2000881. [PMID: 32439736 DOI: 10.1183/13993003.00881-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Montes de Oca M, López Varela MV, Acuña A, Schiavi E, Casas A, Tokumoto A, Torres Duque CA, Ramírez-Venegas A, García G, Camelier A, Bergna M, Cohen M, Sanchez-Angarita E, Guzmán S, Czischke K, Barros M, Rey A. Incorporating New Evidence on Inhaled Medications in COPD. The Latin American Chest Association (ALAT) 2019. Arch Bronconeumol 2019; 56:106-113. [PMID: 31767208 DOI: 10.1016/j.arbres.2019.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/30/2019] [Accepted: 09/11/2019] [Indexed: 02/07/2023]
Abstract
This document on COPD from the Latin American Chest Association (ALAT-2019) uses PICO methodology to analyze new evidence on inhaled medication and answer clinical questions. The following key points emerged from this analysis: 1) evidence is lacking on the comparison of short-acting vs. long-acting bronchodilators in patients with mild COPD; patients with moderate-to-severe COPD obtain greater benefit from long-acting bronchodilators; 2) the benefits of monotherapy with long-acting antimuscarinic agents (LAMA) and combined therapy with long-acting β2-agonists and inhaled corticosteroids (LABA/ICS) are similar, although the latter is associated with a greater risk of pneumonia; 3) LABA/LAMA offer greater benefits in terms of lung function and risk of exacerbation than LABA/ICS (the latter involve an increased risk of pneumonia), 4) LAMA/LABA/ICS have greater therapeutic benefits than LABA/LAMA on the risk of moderate-severe exacerbations. With regard to the role of eosinophils in guiding the use of ICS, ICS withdrawal must be considered when the initial indication was wrong or no response is elicited, in patients with side effects such as pneumonia, and in patients with a low risk of exacerbation and an eosinophil blood count of <300 cells/μl. All this evidence, categorized according to the severity of the obstruction, symptoms, and risk of exacerbations, has been used to generate an algorithm for the use of inhaled medication in COPD.
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Affiliation(s)
- María Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela.
| | | | - Agustín Acuña
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela; Departamento de Investigación y Estadística, ITSalud/Medsolid, Caracas, Venezuela
| | - Eduardo Schiavi
- SubSecretaría de Planificación Sanitaria, Ministerio de Salud, Gobierno de la Ciudad Autónoma de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | | | | | | | - Aquiles Camelier
- Universidade do Estado da Bahia e Escola Bahiana de Medicina, Salvador, Brasil
| | - Miguel Bergna
- Hospital Dr. Antonio Cetrángolo, Vicente López, Buenos Aires, Argentina
| | - Mark Cohen
- Hospital Centro Médico, Guatemala, Guatemala
| | - Efraín Sanchez-Angarita
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela; Departamento de Investigación y Estadística, ITSalud/Medsolid, Caracas, Venezuela
| | | | - Karen Czischke
- Clínica Alemana de Santiago, Hospital Padre Hurtado, Universidad del Desarrollo, San Ramón, Región Metropolitana, Chile
| | - Manuel Barros
- Escuela de Medicina, Universidad de Valparaíso, Hospital C. Van Buren, Valparaíso, Región de Valparaíso, Chile
| | - Alejandra Rey
- Universidad de la República, Hospital Maciel, Montevideo, Uruguay
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LABAs and p38MAPK Inhibitors Reverse the Corticosteroid-Insensitivity of IL-8 in Airway Smooth Muscle Cells of COPD. J Clin Med 2019; 8:jcm8122058. [PMID: 31766770 PMCID: PMC6947523 DOI: 10.3390/jcm8122058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/04/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
Airway inflammation in chronic obstructive pulmonary disease (COPD) is partially insensitive/resistant to inhaled corticosteroids (ICS). ICS plus bronchodilator therapy has been discussed for COPD phenotypes with frequent exacerbations and participation of corticosteroid-sensitive type 2/eosinophilic inflammation. Neutralization of non-type 2/IL-8-associated airway inflammation by reversion of its corticosteroid-resistance might be a future strategy for other phenotypes. Human airway smooth muscle cells (HASMCs) produce corticosteroid-insensitive IL-8 in response to TNFα or LPS in stable disease stages or bacteria-induced exacerbations, respectively. p38-mitogen-activated-protein-kinases (p38MAPKs) are alternative therapeutic targets. Hypothesis: long-acting-β2-agonists (LABAs) reverse the corticosteroid-insensitivity of IL-8 by p38MAPK inhibition in HASMCs. Cultivated HASMCs from COPD subjects were pre-incubated with formoterol, salmeterol, fluticasone-propionate, BIRB796 (p38MAPKα, -γ, -δ inhibitor), and/or SB203580 (p38MAPKα and -β inhibitor) before stimulation with TNFα or LPS. IL-8 and MAPK-activities were measured by ELISA. Formoterol, salmeterol, and fluticasone did not or hardly reduced TNFα- or LPS-induced IL-8. BIRB796 and SB203580 reduced TNFα-induced IL-8. SB203580 reduced LPS-induced IL-8. Fluticasone/formoterol, fluticasone/salmeterol, and fluticasone/BIRB796, but not fluticasone/SB203580 combinations, reduced TNFα-induced IL-8 stronger than single treatments. All combinations including fluticasone/SB203580 reduced LPS-induced IL-8 stronger than single treatments. TNFα induced p38MAPKα and -γ activity. LPS induced p38MAPKα activity. Formoterol reduced TNFα-induced p38MAPKγ and LPS-induced p38MAPKα activity. LABAs reverse the corticosteroid-insensitivity of IL-8 in airway smooth muscles via p38MAPKγ in stable disease and via p38MAPKα in exacerbations. Our pre-clinical data indicate a utility for also adding ICS in non-type 2 inflammatory COPD phenotypes to bronchodilator therapy. Depending on phenotype and disease stage, isoform-specific p38MAPK blockers might also reverse corticosteroid-resistance in COPD.
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Radovanovic D, Contoli M, Marco FD, Sotgiu G, Pelaia G, Braido F, Corsico AG, Micheletto C, Rogliani P, Scichilone N, Saderi L, Santus P, Solidoro P. Clinical and Functional Characteristics of COPD Patients Across GOLD Classifications: Results of a Multicenter Observational Study. COPD 2019; 16:215-226. [PMID: 31500459 DOI: 10.1080/15412555.2019.1659760] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease. The severity grading systems proposed by the Global initiative for Chronic Obstructive Lung Disease (GOLD) have changed over time. The aim of the study was to evaluate if the different GOLD classifications can capture the complexity of the disease by investigating the distribution of lung function and clinical parameters across the GOLD classification systems. This was an observational, retrospective, multicentre study. COPD patients were stratified according to the GOLD severity grading proposed in the 2007, and to the ABCD assessment tool present in the 2011, and 2017 versions of the initiative. Data from body plethysmography, DLCO, comorbidities, exacerbation history, pharmacological therapy and eosinophil counts were collected. A total of 1360 patients (73.4% males) were included in the analysis. Overall, 37% of the patients were severe-very severe according to GOLD 2007. Compared with GOLD 2011, applying the GOLD 2017 criteria, the proportion of the at risk categories (C and D) was reduced by ∼23%. Impairment in inspiratory capacity, DLCO and the prevalence of emphysema paralleled the GOLD 2007 classification only. The proportion of patients with ≥ 200 eosinophils/µL was higher in GOLD 2007 stages 3-4 compared with stages 1-2 (P = 0.008). Eosinophil levels were similar across risk classes in GOLD 2011 and 2017. Overall, 41.8% and 52.4% of the patients in the low risk groups according to GOLD 2011 and 2017 were exposed to inhaled corticosteroids. The GOLD 2011 and 2017 classifications, despite exploring symptoms and exacerbations, might miss other relevant patients' clinical characteristics such as lung function and phenotypes, which have a significant impact on outcomes and disease severity.
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Affiliation(s)
- Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi di Milano, Division of Pulmonary Diseases, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco , Milan , Italy
| | - Marco Contoli
- Section of Internal and Cardiorespiratory Medicine, Department of Medical Sciences, University of Ferrara , Ferrara , Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università Degli Studi di Milano, Respiratory Unit, ASST, Ospedale Papa Giovanni XXIII , Bergamo , Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari , Sassari , Italy
| | - Girolamo Pelaia
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, Magna Graecia University of Catanzaro , Catanzaro , Italy
| | - Fulvio Braido
- Respiratory Disease and Allergy Clinic, Department of Internal Medicine, Ospedale Policlinico IRCCS San Martino di Genova , Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation, Department of Internal Medicine and Therapeutics, University of Pavia , Pavia , Italy
| | - Claudio Micheletto
- UOC Pneumologia, Azienda Ospedaliera Universitaria Integrata , Verona , Italy
| | - Paola Rogliani
- Department of Experimental Medicine and Surgery, School of Respiratory Medicine, University of Rome Tor Vergata , Rome , Italy.,Department of Experimental Medicine and Surgery, University of Rome Tor Vergata , Rome , Italy
| | - Nicola Scichilone
- Department of Biomedicine and Internal and Specialistic Medicine, University of Palermo , Palermo , Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari , Sassari , Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi di Milano, Division of Pulmonary Diseases, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco , Milan , Italy
| | - Paolo Solidoro
- Cardiovascular and Thoracic Department, SC Pneumologia U, Città Della Salute e Della Scienza (Molinette) University Hospital , Turin , Italy
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The Airways' Mechanical Stress in Lung Disease: Implications for COPD Pathophysiology and Treatment Evaluation. Can Respir J 2019; 2019:3546056. [PMID: 31583033 PMCID: PMC6748188 DOI: 10.1155/2019/3546056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/14/2019] [Indexed: 11/17/2022] Open
Abstract
The airway epithelium stretches and relaxes during the normal respiratory cycle, and hyperventilation exaggerates this effect, resulting in changes in lung physiology. In fact, stretching of the airways influences lung function and the secretion of airway mediators, which in turn may cause a potentially injurious inflammatory response. This aim of the present narrative review was to illustrate the current evidence on the importance of mechanical stress in the pathophysiology of lung diseases with a particular focus on chronic obstructive pulmonary disease (COPD) and to discuss how this may influence pharmacological treatment strategies. Overall, treatment selection should be tailored to counterpart the effects of mechanical stress, which influences inflammation both in asthma and COPD. The most suitable treatment approach between a long-acting β2-agonists/long-acting antimuscarinic-agonist (LABA/LAMA) alone or with the addition of inhaled corticosteroids should be determined based on the underlying mechanism of inflammation. Noteworthy, the anti-inflammatory effects of the glycopyrronium/indacaterol combination on hyperinflation and mucociliary clearance may decrease the rate of COPD exacerbations, and it may synergistically improve bronchodilation with a double action on both the cyclic adenosine monophosphate (cAMP) and the acetylcholine pathways.
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Abstract
Chronic obstructive pulmonary disease (COPD) is a major global health problem that is poorly treated by current therapies as it has proved difficult to treat the underlying inflammation, which is largely corticosteroid-resistant in most patients. Although rare genetic endotypes of COPD have been recognized, despite the clinical heterogeneity of COPD, it has proved difficult to identify distinct inflammatory endotypes. Most patients have increased neutrophils and macrophages in sputum, reflecting the increased secretion of neutrophil and monocyte chemotactic mediators in the lungs. However, some patients also have increased eosinophils in sputum and this may be reflected by increased blood eosinophils. Increased blood and sputum eosinophils are associated with more frequent exacerbations and predict a good response to corticosteroids in reducing and treating acute exacerbations. Eosinophilic COPD may represent an overlap with asthma but the mechanism of eosinophilia is uncertain as, although an increase in sputum IL-5 has been detected, anti-IL-5 therapies are not effective in preventing exacerbations. More research is needed to link inflammatory endotypes to clinical manifestations and outcomes in COPD and in particular to predict response to precision medicines.
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Affiliation(s)
- Peter J. Barnes
- National Heart and Lung Institute Imperial College London UK
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Vanfleteren LEGW, Ullman A, Nordenson A, Andersson A, Andelid K, Fabbri LM. Triple therapy (ICS/LABA/LAMA) in COPD: thinking out of the box. ERJ Open Res 2019; 5:00185-2018. [PMID: 30775372 PMCID: PMC6368994 DOI: 10.1183/23120541.00185-2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/19/2018] [Indexed: 01/10/2023] Open
Abstract
A current hot topic in COPD is that two “fixed triple” combinations of an inhaled corticosteroid (ICS), a long-acting β2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) in a single inhaler have become available for patients with COPD, and a third triple therapy is in advanced development with the first large randomised clinical trial (RCT) recently published in Lancet Respiratory Medicine [1]. The triple therapies available in a single inhaler are: beclomethasone-dipropionate/formoterol/glycopyrronium (BDP/FF/G); fluticasone-furoate/vilanterol/umeclidinium (FLF/VI/UMEC); and budesonide/glycopyrronium/formoterol (B/G/F). Triple inhaler therapy in COPD might in some real-life situations be useful outside of the strict indications reported by the registration agencies, but at the same time in some other situations it could be better avoided, even when recommendedhttp://ow.ly/CbOe30njXV2
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Affiliation(s)
- Lowie E G W Vanfleteren
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Anders Ullman
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Anita Nordenson
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Anders Andersson
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Andelid
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Leonardo M Fabbri
- COPD center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
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Adding a LAMA to ICS/LABA Therapy: A Meta-analysis of Triple Combination Therapy in COPD. Chest 2019; 155:758-770. [PMID: 30660781 DOI: 10.1016/j.chest.2018.12.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/17/2018] [Accepted: 12/14/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) combination is commonly prescribed to treat COPD; therefore, we performed a meta-analysis on the effect of adding a long-acting muscarinic receptor antagonist (LAMA) to ICS/LABA combination in COPD. METHODS Studies were identified by searching in different databases the randomized controlled trials that investigated the effect of ICS/LABA/LAMA combination in COPD. The primary end points were the effect of triple therapy on trough FEV1, risk of acute exacerbation of COPD (AECOPD), and risk of cardiovascular serious adverse events (SAEs), compared with ICS/LABA combination. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the quality of evidence. RESULTS Thirteen randomized controlled trials including 15,519 patients with COPD (ICS/LABA/LAMA combination, 53.1%; ICS/LABA combination, 46.9%) were meta-analyzed. ICS/LABA/LAMA combination improved trough FEV1 (mean difference, +104.86 mL; 95% CI, 86.74-122.99; high quality of evidence) and protected against AECOPD (relative risk, 0.78; 95% CI, 0.71-0.85; high quality of evidence) vs ICS/LABA combination. For every approximately four patients treated with triple therapy, one increased FEV1 > 100 mL, and approximately 26 patients had to be treated for 1 year with ICS/LABA/LAMA combination to prevent one AECOPD, compared with ICS/LABA combination. Adding a LAMA to ICS/LABA therapy did not modulate the risk of cardiovascular SAEs (moderate quality of evidence). CONCLUSIONS Triple therapy provides significant clinical benefit in patients with COPD on ICS/LABA combination. ICS/LABA therapy can be escalated to triple therapy without a real risk to increase cardiovascular SAEs when a LAMA is added to the combination. TRIAL REGISTRY ClinicalTrials.gov; No.: CRD42018095300; URL: www.clinicaltrials.gov.
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Cazzola M, Rogliani P, Calzetta L, Matera MG. Triple therapy versus single and dual long-acting bronchodilator therapy in COPD: a systematic review and meta-analysis. Eur Respir J 2018; 52:13993003.01586-2018. [PMID: 30309975 DOI: 10.1183/13993003.01586-2018] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/03/2018] [Indexed: 01/31/2023]
Abstract
We performed a meta-analysis to compare the impact of triple combination therapy with inhaled corticosteroids (ICS), long-acting β2-agonists (LABAs) and long-acting muscarinic receptor antagonists (LAMAs) versus LABA/LAMA combination therapy or single long-acting bronchodilator therapy in chronic obstructive pulmonary disease. The ICS/LABA/LAMA combination reduced the risk of exacerbation (relative risk 0.70, 95% CI 0.53-0.94) and improved trough forced expiratory volume in 1 s (mean difference in mL +37.94, 95% CI 18.83-53.89) versus LABA/LAMA combination therapy. The protective effect of triple combination therapy versus LABA/LAMA combination therapy against risk of exacerbation was greater in patients with blood eosinophil counts ≥300 cells·µL-1 (relative risk 0.57, 95% CI 0.48-0.68). While ∼38 patients had to be treated for 1 year with ICS/LABA/LAMA combination therapy to prevent one exacerbation compared to LABA/LAMA combination therapy, the number needed to treat (NNT) was ∼21 when compared to single long-acting bronchodilator therapy. The person-based NNT per year of ICS/LABA/LAMA combination therapy versus LABA/LAMA combination therapy was significantly (p<0.05) lower in patients with eosinophil counts ≥300 cells·µL-1 (NNT value: 8.58) than in those with counts <300 cells·µL-1 (NNT value: 46.28). The risk of pneumonia did not differ between ICS/LABA/LAMA combination therapy and its comparators. The number needed to harm was ∼195. This meta-analysis suggests that patients on single long-acting bronchodilator therapy or LABA/LAMA combination therapy, who still have exacerbations and have blood eosinophil counts ≥300 cells·µL-1, could benefit from ICS/LABA/LAMA combination therapy.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Dept of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Medicine, Dept of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Anzueto A, Miravitlles M. Considerations for the Correct Diagnosis of COPD and Its Management With Bronchodilators. Chest 2018. [PMID: 29524387 DOI: 10.1016/j.chest.2018.02.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
COPD is often misdiagnosed and inappropriately treated in many patients. COPD is a distinct disease from adult-onset asthma; however, some patients with COPD may present with several forms of airway disease described as asthma-COPD overlap (ACO). Bronchodilators and inhaled corticosteroids (ICS) both have a place in standard maintenance treatment of COPD and asthma; however, recommendations for use differ widely. In patients with COPD, long-acting bronchodilators are effective initial monotherapy treatment, whereas ICS monotherapy is recommended as initial treatment in patients with asthma. Clinicians need to be confident in their diagnosis to ensure that correct treatment is given because misguided treatment decisions can result in significantly increased safety risks for patients. This review highlights the differences in diagnosis and treatment between COPD, asthma, and ACO and discusses the data supporting guideline recommendations for use of bronchodilators in COPD treatment in contrast to asthma or ACO.
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Affiliation(s)
- Antonio Anzueto
- Pulmonary/Critical Care, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitario Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Balkissoon R. New Treatment Options for COPD: How Do We Decide Phenotypes, Endotypes or Treatable Traits? CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:72-80. [PMID: 29629407 DOI: 10.15326/jcopdf.5.1.2018.0128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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