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Brunton SA, Hogarth DK. Overuse of long-acting β 2-agonist/inhaled corticosteroids in patients with chronic obstructive pulmonary disease: time to rethink prescribing patterns. Postgrad Med 2023; 135:784-802. [PMID: 38032494 DOI: 10.1080/00325481.2023.2284650] [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: 09/18/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality globally. In the major revision of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report, the scientific committee concluded that the use of long-acting β2-agonist/inhaled corticosteroids (LABA/ICS) is not encouraged in patients with COPD. However, current prescribing patterns reveal significant use of LABA/ICS. In this paper, the evidence behind the current practice and the latest treatment recommendations is reviewed. We compare the efficacy and safety of combination therapy with long-acting muscarinic antagonist (LAMA) and LABA vs LABA/ICS and note that LAMA/LABA combinations have reduced the annual rate of moderate/severe exacerbations, delayed the time to first exacerbation, and increased post-dose FEV1 vs ICS-based regimens. The GOLD 2023 report recommends treatment with LABA and LAMA combination (preferably as a single inhaler) in patients with persistent dyspnea, with initiation of ICS in patients based on the symptoms (dyspnea and exercise intolerance as indicated by modified Medical Research Council [mMRC] score ≥ 2 and COPD Assessment Test [CAT™] > 20), blood eosinophil count (≥ 300 cells/µL), and exacerbation history (history of hospitalizations for exacerbations of COPD and ≥ 2 moderate exacerbations per year despite appropriate long-acting bronchodilator maintenance therapy). We describe practical recommendations for primary care physicians to optimize therapy for their patients and prevent overuse of ICS-based regimens. We advocate adherence to current recommendations and a greater focus on effective treatments to successfully control symptoms, minimize exacerbation risk, preserve lung function, maximize patient outcomes, and reduce the burden of drug-related adverse events.
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Affiliation(s)
| | - D Kyle Hogarth
- Pulmonary and Critical Care Medicine, The University of Chicago Medicine, Chicago, IL, USA
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2
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Weng CF, Wu CC, Wu MH, Lin FJ. Comparison of Clinical Outcomes Among Different Fixed-Dose Combinations of Long-Acting Muscarinic Antagonists and Long-Acting β 2-Agonists in Patients With COPD. Chest 2022; 163:799-814. [PMID: 36442662 DOI: 10.1016/j.chest.2022.11.027] [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: 05/17/2022] [Revised: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Researchers have yet to obtain conclusive evidence differentiating among fixed-dose combinations (FDCs) of long-acting muscarinic antagonists (LAMAs) and long-acting beta-agonists (LABAs) for COPD in terms of real-world clinical outcomes. RESEARCH QUESTION What are the differences between available LAMA/LABA FDCs on the risk of acute exacerbation (AE) and cardiovascular events? STUDY DESIGN AND METHODS This retrospective cohort study based on a national insurance claims database included patients with COPD ≥ 40 years of age who were newly prescribed glycopyrronium (GLY)/indacaterol (IND), umeclidinium (UMEC)/vilanterol (VI), or tiotropium (TIO)/olodaterol (OLO) FDC between January 1, 2015, and June 30, 2019. Propensity score matching and Cox regression models were used to compare outcomes of AE and cardiovascular events associated with LAMA/LABA FDC treatment. RESULTS Among the 44,498 patients identified and included, 15,586 received GLY/IND, 20,460 received UMEC/VI, and 8,452 received TIO/OLO. Baseline characteristics were well balanced after 1:1 matching of UMEC/VI and GLY/IND, 2:1 matching of UMEC/VI and TIO/OLO, and 2:1 matching of GLY/IND and TIO/OLO. Risk of severe AE was lower among patients treated with UMEC/VI or GLY/IND than among those who received TIO/OLO (UMEC/VI vs TIO/OLO: 17.85 vs 29.32 per 100 person-years; hazard ratio, 0.76; 95% CI, 0.68-0.84; GLY/IND vs TIO/OLO: 15.54 vs 25.53 per 100 person-years; hazard ratio, 0.77; 95% CI, 0.67-0.88). In addition, GLY/IND users tended to have a lower risk of cardiovascular events than TIO/OLO users, but the difference dissipated when restricting follow up to a shorter duration. INTERPRETATION Our results revealed that the risk of severe AE was lower among patients with COPD receiving UMEC/VI or GLY/IND than among those receiving TIO/OLO, whereas the incidence of cardiovascular events was similar across groups but was slightly lower in GLY/IND users when compared with TIO/OLO users. Further research will be required to confirm these findings.
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Affiliation(s)
- Ching-Fu Weng
- Division of Pulmonary Medicine, Department of Internal Medicine, Hsinchu Cathay General Hospital, Hsinchu; School of Medicine, National Tsing Hua University, Hsinchu
| | - Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei; School of Pharmacy, College of Medicine, National Taiwan University, Taipei
| | - Mei-Hsuan Wu
- Teaching and Research Center, Hsinchu Cathay General Hospital, Hsinchu; Precision Medicine Ph.D. Program, National Tsing Hua University, Hsinchu
| | - Fang-Ju Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei; School of Pharmacy, College of Medicine, National Taiwan University, Taipei; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Mummy DG, Coleman EM, Wang Z, Bier EA, Lu J, Driehuys B, Huang YC. Regional Gas Exchange Measured by 129 Xe Magnetic Resonance Imaging Before and After Combination Bronchodilators Treatment in Chronic Obstructive Pulmonary Disease. J Magn Reson Imaging 2021; 54:964-974. [PMID: 33960534 PMCID: PMC8363573 DOI: 10.1002/jmri.27662] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 12/22/2022] Open
Abstract
Background Hyperpolarized 129Xe magnetic resonance imaging (MRI) provides a non‐invasive assessment of regional pulmonary gas exchange function. This technique has demonstrated that chronic obstructive pulmonary disease (COPD) patients exhibit ventilation defects, reduced interstitial barrier tissue uptake, and poor transfer to capillary red blood cells (RBCs). However, the behavior of these measurements following therapeutic intervention is unknown. Purpose To characterize changes in 129Xe gas transfer function following administration of an inhaled long‐acting beta‐agonist/long‐acting muscarinic receptor antagonist (LABA/LAMA) bronchodilator. Study Type Prospective. Population Seventeen COPD subjects (GOLD II/III classification per Global Initiative for Chronic Obstructive Lung Disease criteria) were imaged before and after 2 weeks of LABA/LAMA therapy. Field Strength/Sequences Dedicated ventilation imaging used a multi‐slice 2D gradient echo sequence. Three‐dimensional images of ventilation, barrier uptake, and RBC transfer used an interleaved, radial, 1‐point Dixon sequence. Imaging was acquired at 3 T. Assessment 129Xe measurements were quantified before and after LABA/LAMA treatment by ventilation defect + low percent (vendef + low) and by barrier uptake and RBC transfer relative to a healthy reference population (bar%ref and RBC%ref). Pulmonary function tests, including diffusing capacity of the lung for carbon monoxide (DLCO), were also performed before and after treatment. Statistical Tests Paired t‐test, Pearson correlation coefficient (r). Results Baseline vendef + low was 57.8 ± 8.4%, bar%ref was 73.2 ± 19.6%, and RBC%ref was 36.5 ± 13.6%. Following treatment, vendef + low decreased to 52.5 ± 10.6% (P < 0.05), and improved in 14/17 (82.4%) of subjects. However, RBC%ref decreased in 10/17 (58.8%) of subjects. Baseline measurements of bar%ref and DLCO were correlated with the degree of post‐treatment change in vendef + low (r = −0.49, P < 0.05 and r = −0.52, P < 0.05, respectively). Conclusion LABA/LAMA therapy tended to preferentially improve ventilation in subjects whose 129Xe barrier uptake and DLCO were relatively preserved. However, newly ventilated regions often revealed RBC transfer defects, an aspect of lung function opaque to spirometry. These microvasculature abnormalities must be accounted for when assessing the effects of LABA/LAMA therapy. Level of Evidence 1 Technical Efficacy Stage 4
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Affiliation(s)
- David G Mummy
- Center for In Vivo Microscopy, Duke University, Durham, North Carolina, USA.,Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Erika M Coleman
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Ziyi Wang
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Elianna A Bier
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Junlan Lu
- Department of Medical Physics, Duke University, Durham, North Carolina, USA
| | - Bastiaan Driehuys
- Center for In Vivo Microscopy, Duke University, Durham, North Carolina, USA.,Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Department of Medical Physics, Duke University, Durham, North Carolina, USA
| | - Yuh-Chin Huang
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Lee JH, Park YH, Kang DR, Lee SJ, Lee MK, Kim SH, Yong SJ, Lee WY. Risk of Pneumonia Associated with Inhaled Corticosteroid in Patients with Chronic Obstructive Pulmonary Disease: A Korean Population-Based Study. Int J Chron Obstruct Pulmon Dis 2020; 15:3397-3406. [PMID: 33402820 PMCID: PMC7778438 DOI: 10.2147/copd.s286149] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Inhaled corticosteroids (ICSs) are recommended for patients with frequent exacerbation of chronic obstructive pulmonary disease (COPD). However, accumulating evidence has indicated the risk of pneumonia from the use of ICS. This study aimed to investigate the association between ICS and pneumonia in the real-world clinical setting. Methods A retrospective cohort study was performed using nationwide population data from the Korea National Health Insurance Service. Subjects who had a new diagnosis of COPD and who received inhaled bronchodilators without a diagnosis of pneumonia before the initiation of bronchodilators were identified. Subjects were followed up until their first diagnosis of pneumonia. The risk of pneumonia in ICS users was compared to that in non-ICS users. Results A total of 87,594 subjects were identified and 1:1 matched to 22,161 ICS users and non-ICS users. More ICS users were diagnosed with pneumonia compared to non-ICS users (33.73% versus 24.51%, P<0.0001). The incidence rate per 100,000 person-years was 8904.98 for ICS users and 6206.79 for non-ICS users. The hazard ratio (HR) of pneumonia for ICS users was 1.62 (95% CI 1.54–1.70). The HR of subjects prescribed with the lowest ICS cumulative dose was 1.35 (1.27–1.43). The HR increased to 1.51 (1.42–1.60), 1.96 (1.85–2.09), and 2.03 (1.89–2.18) as the cumulative dose increased. Pneumonia was strongly associated with fluticasone propionate (1.79 (1.70–1.89)) and fluticasone furoate (1.80 (1.61–2.01)) use, compared to the use of other types of ICS. Conclusion ICS increases the risk of pneumonia in patients with COPD. Hence, ICS should be carefully prescribed in patients with risk factors for pneumonia while considering the cumulative doses and subtypes of ICS.
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Affiliation(s)
- Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - You Hyun Park
- Department of Biostatistics, Yonsei University, Seoul, Korea
| | - Dae Ryong Kang
- Department of Precision Medicine & Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Jeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Myoung Kyu Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang-Ha Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Suk Joong Yong
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Molina París J, Alonso Hernández PM, Díez García JA, Gonzalez Uribe-Etxebarria I, Yelo García J, Galera Llorca J, Aguilar H, Ribera X. Assessment of physical functioning in patients with chronic obstructive pulmonary disease (COPD) requiring long-acting dual bronchodilation in routine clinical practice. Semergen 2020; 47:295-304. [PMID: 33359383 DOI: 10.1016/j.semerg.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/23/2020] [Accepted: 10/30/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We aim to determine the effect of a fixed-dose combination (FDC) of tiotropium/olodaterol on Physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) in a real world setting. METHODS COPD patients were prospectively enrolled to evaluate the effect of a FDC of tiotropium/olodaterol inhaler therapy via the Respimat® Soft Mist™ inhaler (SMI) on the physical functioning scale (PF-10), and the general condition of the patient as assessed by the physician (Physician's Global Evaluation, PGE), and the patient's satisfaction after 6 weeks of treatment. The primary end-point was the percentage of patients with therapeutic success at 6th week follow-up, defined as a ≥10-points increase in the standardised PF-10 score from baseline. RESULTS A total of 257 patients from 57 sites were enrolled, and 234 completed the follow up. After 6 weeks of treatment, 155 out of 234 patients (66.2%) showed therapeutic success in the physical functioning score, coupled with significant improvement in PGE score: 78 (33.3%) patients with good/excellent PGE score at baseline, increasing to 172 (73.5%) at 6th week (p<0.0001). The patient's satisfaction was excellent: 77.2% reporting to be satisfied/very satisfied with the treatment, 79.9% with inhaling and 79.0% with the handling of SMI device. 1.6% of patients reported an investigator-defined drug-related adverse event. CONCLUSION Treatment of COPD patients with a FDC of tiotropium/olodaterol SMI for 6 weeks resulted in significant improvements in the patients' condition as assessed by patients and physicians, with no new safety findings.
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Affiliation(s)
| | | | | | | | | | | | - H Aguilar
- Boehringer Ingelheim España, Sant Cugat del Vallés, Barcelona, Spain
| | - X Ribera
- Boehringer Ingelheim España, Sant Cugat del Vallés, Barcelona, Spain.
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Balkissoon R. Journal Club-COPD2020 Update. Global Initiative for Chronic Obstructive Lung Disease 2020 Report and the Journal of the COPD Foundation Special Edition, Moving to a New Definition for COPD: "COPDGene ® 2019". CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 6. [PMID: 31999904 DOI: 10.15326/jcopdf.7.1.2020.0133] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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7
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Avdeev SN, Trushenko NV. New opportunities of dual bronchodilation therapy for patients with chronic obstructive pulmonary disease. TERAPEVT ARKH 2019; 91:76-85. [PMID: 31094464 DOI: 10.26442/00403660.2019.03.000136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Currently, combinations of long-acting beta2-agonists and long-acting anticholinergics are considered as the basic therapy for majority of patients with chronic obstructive pulmonary disease (COPD). These combinations have different pharmacological characteristics and delivery devices that provides different clinical effects and new opportunities for personalized treatment of COPD. Aclidinium/formoterol fixed combination differs from other dual bronchodilators by twice-daily dosing regimen, good safety profile and a specific delivery system. Recent information on clinical efficacy and safety of aclidinium/formoterol combination in COPD patients is given in this article.
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Affiliation(s)
- S N Avdeev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia.,Pulmonology Scientific Research Institute under Federal Medical and Biological Agency of Russian Federation, Moscow, Russia
| | - N V Trushenko
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia.,Pulmonology Scientific Research Institute under Federal Medical and Biological Agency of Russian Federation, Moscow, Russia
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