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Cazzola M, Rogliani P, Ora J, Calzetta L, Matera MG. Cardiovascular diseases or type 2 diabetes mellitus and chronic airway diseases: mutual pharmacological interferences. Ther Adv Chronic Dis 2023; 14:20406223231171556. [PMID: 37284143 PMCID: PMC10240559 DOI: 10.1177/20406223231171556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/06/2023] [Indexed: 06/08/2023] Open
Abstract
Chronic airway diseases (CAD), mainly asthma and chronic obstructive pulmonary disease (COPD), are frequently associated with different comorbidities. Among them, cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) pose problems for the simultaneous treatment of CAD and comorbidity. Indeed, there is evidence that some drugs used to treat CAD negatively affect comorbidity, and, conversely, some drugs used to treat comorbidity may aggravate CAD. However, there is also growing evidence of some beneficial effects of CAD drugs on comorbidities and, conversely, of the ability of some of those used to treat comorbidity to reduce the severity of lung disease. In this narrative review, we first describe the potential cardiovascular risks and benefits for patients using drugs to treat CAD and the potential lung risks and benefits for patients using drugs to treat CVD. Then, we illustrate the possible negative and positive effects on T2DM of drugs used to treat CAD and the potential negative and positive impact on CAD of drugs used to treat T2DM. The frequency with which CAD and CVD or T2DM are associated requires not only considering the effect that drugs used for one disease condition may have on the other but also providing an opportunity to develop therapies that simultaneously favorably impact both diseases.
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Affiliation(s)
| | - Paola Rogliani
- Chair of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
- Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Chair of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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2
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Design of the Reducing Diagnostic Error to Improve Patient Safety (REDEfINE) in COPD and asthma study: A cluster randomized comparative effectiveness trial. Contemp Clin Trials 2022; 123:106971. [PMID: 36280032 DOI: 10.1016/j.cct.2022.106971] [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: 06/14/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 01/27/2023]
Abstract
Although spirometry is a simple, portable test and recommended for the diagnosis of asthma and chronic obstructive pulmonary disease (COPD), it is not routinely used in the primary care setting. Minorities and underserved populations are less likely to have spirometry assessment, leading to both over and misdiagnosis of asthma and COPD. Because dyspnea is a common symptom across multiple diseases, use of spirometry as a diagnostic tool is important. Missed, delayed, or misdiagnosis of asthma and COPD, which are considered diagnostic errors (DE), can lead to poor quality of care, increased morbidity and mortality, and increased costs to patients and health systems. Barriers to the use of spirometry have been identified at clinician/clinic and health systems levels. The REDEFINE program is designed to overcome identified barriers to spirometry use in primary care by utilizing health promoters (HPs) who perform spirometry within primary care clinics and work collaboratively with clinicians to incorporate the results at the point of care without interrupting clinic workflow. The REDEFINE trial is a comparative effectiveness study comparing outcomes of the REDEFINE program with usual care (UC) in primary care patients determined to be at increased risk of DE for asthma and COPD. The primary outcome will be all-cause hospitalizations. The secondary outcomes will be the proportion of accurate diagnosis of COPD, asthma, or asthma-COPD overlap based on initial diagnosis and spirometry and all cause and respiratory-related acute outpatient care and emergency department visits. In this report, we describe the design and methods for the REDEFINE trial. Trial registration: NCT03137303https://clinicaltrials.gov/ct2/show/NCT03137303?term=REDEFINE&draw=2&rank=1.
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Cuthbert JJ, Pellicori P, Clark AL. Optimal Management of Heart Failure and Chronic Obstructive Pulmonary Disease: Clinical Challenges. Int J Gen Med 2022; 15:7961-7975. [PMID: 36317097 PMCID: PMC9617562 DOI: 10.2147/ijgm.s295467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022] Open
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common causes of breathlessness which frequently co-exist; one potentially exacerbating the other. Distinguishing between the two can be challenging due to their similar symptomatology and overlapping risk factors, but a timely and correct diagnosis is potentially lifesaving. Modern treatment for HF can substantially improve symptoms and prognosis for many patients and may have beneficial effects for patients with COPD. Conversely, while many inhaled treatments for COPD can improve symptoms and reduce exacerbations, there is conflicting evidence regarding the safety of some inhaled treatments for COPD in patients with HF. Here we explore the overlap between HF and COPD, examine the effect of one condition on the other, and address the challenges of managing patients with both conditions.
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Affiliation(s)
- Joseph J Cuthbert
- Centre for Clinical Sciences, Hull York Medical School, Kingston Upon Hull, East Riding of Yorkshire, UK,Department of Cardiology, Hull University Teaching Hospital Trust, Kingston Upon Hull, East Riding of Yorkshire, UK,Correspondence: Joseph J Cuthbert, Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston Upon Hull, HU16 5JQ, UK, Tel +44 1482 461776, Fax +44 1482 461779, Email
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Andrew L Clark
- Department of Cardiology, Hull University Teaching Hospital Trust, Kingston Upon Hull, East Riding of Yorkshire, UK
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4
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Effects of tiotropium on the risk of coronary heart disease in patients with COPD: a nationwide cohort study. Sci Rep 2022; 12:16674. [PMID: 36198721 PMCID: PMC9535029 DOI: 10.1038/s41598-022-21038-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/22/2022] [Indexed: 11/08/2022] Open
Abstract
Inhaled long-acting muscarinic antagonist (LAMA) is recommended for the treatment of chronic obstructive pulmonary disease (COPD). However, there is still concern that LAMA may cause cardiovascular adverse events in COPD patients. Therefore, this study aimed to determine whether the administration of tiotropium, the first commercially available LAMA, could increase the risk of coronary heart disease (CHD) in COPD patients through a nationwide cohort study. We used the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) database between 2002 and 2014 for the analysis. We applied a washout period of COPD diagnosis during 2002–2003 and excluded the patients who used an inhaler before the diagnosis of COPD. We also excluded patients who were diagnosed with CHD before inhaler use. Among a total of 5787 COPD patients, 1074 patients were diagnosed with CHD. In the Cox regression models with time-dependent tiotropium usage, we found that tiotropium significantly increased the risk of CHD in a subgroup of age \documentclass[12pt]{minimal}
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\begin{document}$$\ge \hspace{0.17em}$$\end{document}≥55 years compared to non-users of tiotropium (adjusted hazard ratio [aHR], 1.24; 95% confidence interval [CI], 1.003–1.54). When analyzed by dividing into tertiles (high/middle/low) according to the cumulative tiotropium exposure, the high tertile exposure group of tiotropium was associated with a higher risk of CHD compared with the low tertile exposure group of tiotropium. Additionally, the risk of CHD was higher in the high tertile exposure group of tiotropium in the age 55 and older group and in the never smoker group. When prescribing tiotropium for COPD patients, particularly those over 55 years of age and never-smokers, it is desirable to evaluate the risk of CHD in advance and closely follow-up for CHD occurrence.
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Altawalbeh SM, Almomani BA, Alefan Q, Mohammad Momany S, Al-Share QY. The influence of adverse drug effects on health-related quality of life in chronic obstructive pulmonary disease patients. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:457-465. [PMID: 35849340 DOI: 10.1093/ijpp/riac052] [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: 09/25/2021] [Accepted: 05/23/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Concerns have been raised about the influence of adverse drug effects on patient's health-related quality of life (HRQoL) in COPD patients. This study aimed to evaluate the impact of COPD treatment-related adverse effects on HRQoL in COPD patients. METHODS In a cross-sectional study, COPD patients aged 40 years or older were identified and interviewed during their hospital visits. The EuroQol 5 Dimension 5 Level (EQ-5D-5L) questionnaire was used for evaluating HRQoL. Potential treatment adverse effects were evaluated as experienced by participants during the last 2 weeks preceding the interview. The intensity of adverse effects was reported in the following categories: never, mild, moderate and severe. Multivariable linear regression model was performed to evaluate the influence of adverse drug effects on utility scores as an indicator of HRQoL. KEY FINDINGS A total of 203 patients diagnosed with COPD were recruited in the current study. The mean utility score of the study sample was 0.68 (SD = 0.36). Moderate-severe constipation, moderate-severe confusion, mild urinary hesitation, moderate-severe urinary hesitation, moderate-severe dry eyes and moderate-severe drowsiness were significant predictors/determinants for the average utility scores (coefficients were -0.099, -0.191, -0.111, -0.157 and -0.144, respectively). In addition, having higher COPD Assessment Test scores and severe disease was negatively associated with average utility scores (coefficients were -0.287 and -0.124, respectively). CONCLUSIONS Higher intensity of COPD treatment-related adverse effects has a negative influence on HRQoL in COPD patients. Anticholinergic drug effects are of concern in COPD adults' population.
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Affiliation(s)
- Shoroq M Altawalbeh
- Department of Clinical Pharmacy, School of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Basima A Almomani
- Department of Clinical Pharmacy, School of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Qais Alefan
- Department of Clinical Pharmacy, School of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Suleiman Mohammad Momany
- Department of Internal Medicine, School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Qusai Y Al-Share
- Department of Clinical Pharmacy, School of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Gulea C, Zakeri R, Kallis C, Quint JK. Impact of COPD and asthma on in-hospital mortality and management of patients with heart failure in England and Wales: an observational analysis. BMJ Open 2022; 12:e059122. [PMID: 35772828 PMCID: PMC9247695 DOI: 10.1136/bmjopen-2021-059122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the association between having concomitant chronic obstructive pulmonary disease (COPD) or asthma, and in-patient mortality and post-discharge management among patients hospitalised for acute heart failure (HF). SETTING Data were obtained from patients enrolled in the National Heart Failure Audit. PARTICIPANTS 217 329 patients hospitalised for HF in England-Wales between March 2012 and 2018. OUTCOMES In-hospital mortality, referrals to cardiology follow-up and prescriptions for HF medications were compared between patients with comorbid COPD (COPD-HF) or asthma (asthma-HF) versus HF-alone using mixed-effects logistic regression. RESULTS Patients with COPD-HF were more likely to die during hospitalisation, and those with asthma-HF had a reduced likelihood of death, compared with patients who had HF-alone ((adjusted)ORadj, 95% CI: 1.10, 1.06 to 1.14 and ORadj, 95% CI: 0.84, 0.79 to 0.88). In patients who survived to discharge, referral to HF follow-up services differed between groups: patients with COPD-HF had reduced odds of cardiology follow-up (ORadj, 95% CI 0.79, 0.77 to 0.81), while cardiology referral odds for asthma-HF were similar to HF-alone. Overall, proportions of HF medication prescriptions at discharge were low for both COPD-HF and asthma-HF groups, particularly prescriptions for beta-blockers. CONCLUSIONS In this nationwide analysis, we showed that COPD and asthma significantly impact the clinical course in patients hospitalised for HF. COPD is associated with higher in-patient mortality and lower cardiology referral odds, while COPD and asthma are both associated with lower use of prognostic HF therapies on discharge. These data highlight therapeutic gaps and a need for better integration of cardiopulmonary services to improve healthcare provision for patients with HF and coexisting respiratory disease.
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Affiliation(s)
- Claudia Gulea
- National Heart and Lung Institute, Imperial College London, London, UK
- NIHR Imperial Biomedical Research Centre, London, UK
| | - Rosita Zakeri
- British Heart Foundation Centre for Research Excellence, King's College London, London, UK
| | - Constantinos Kallis
- National Heart and Lung Institute, Imperial College London, London, UK
- NIHR Imperial Biomedical Research Centre, London, UK
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
- NIHR Imperial Biomedical Research Centre, London, UK
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7
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Yang X, Yu Y, Wang Y, Jiang W, Jiang W, Yin B. Genetic Polymorphism of Matrix Metalloproteinase 9 and Susceptibility to Chronic Obstructive Pulmonary Disease: A Meta-analysis. J Med Biochem 2022; 41:263-274. [PMID: 36042908 PMCID: PMC9375530 DOI: 10.5937/jomb0-34155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background To systematically analyze the influence of genetic polymorphisms of matrix metalloproteinase 9 (MMP9) on susceptibility to chronic obstructive pulmonary disease (COPD). Methods Relevant literatures reporting MMP9 and susceptibility to COPD in PubMed, Web of Science, VIP, Wanfang and CNKI databases were searched using the key words "matrix metalloproteinases 9/MMP9, COPD/chronic obstructive pulmonary disease". Data of eligible literatures were extracted and analyzed for the odds ratio (OR) and corresponding 95% CI. Results A total of 16 independent studies reporting MMP9-1562C/T and COPD patients were enrolled and analyzed. None of the genetic models revealed the relationship between MMP9-1562C/T and susceptibility to COPD. Subgroup analyses identified lower risk of COPD in Chinese population carrying the TT genotype for theMMP9 rs3918242 relative to those carrying CT and CC genotypes (P=0.03, OR=0.67, 95% CI=0.46-0.97). Conclusions Chinese population carrying the TT genotype for the MMP-9 rs3918242 present lower susceptibility to COPD relative to those carrying CT and CC genotypes.
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Affiliation(s)
- Xiaoping Yang
- Qingdao Hospital of Traditional Chinese Medicine (Haici Hospital), Department 2 of Respiratory and Critical Care (Lung disease) Center, Qingdao, China
| | - Yuanyuan Yu
- Qingdao Hospital of Traditional Chinese Medicine (Haici Hospital), Department of Anesthesiology, Qingdao, China
| | - Yong Wang
- Qingdao Hospital of Traditional Chinese Medicine (Haici Hospital), Department 2 of Respiratory and Critical Care (Lung disease) Center, Qingdao, China
| | - Wen Jiang
- Qingdao Hospital of Traditional Chinese Medicine (Haici Hospital), Department 2 of Respiratory and Critical Care (Lung disease) Center, Qingdao, China
| | - Wenqing Jiang
- Qingdao Hospital of Traditional Chinese Medicine (Haici Hospital), Department 2 of Respiratory and Critical Care (Lung disease) Center, Qingdao, China
| | - Bin Yin
- Qingdao Hospital of Traditional Chinese Medicine (Haici Hospital), Department 2 of Respiratory and Critical Care (Lung disease) Center, Qingdao, China
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8
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The effects of medications for treating COPD and allied conditions on stroke: a population-based cohort study. NPJ Prim Care Respir Med 2022; 32:4. [PMID: 35039513 PMCID: PMC8764093 DOI: 10.1038/s41533-021-00267-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD) are at higher risk of stroke. This study aimed to investigate the clinical factors of stroke risk in COPD and allied conditions patients and associations between medications for treating COPD and allied conditions. The population-based study cohort comprised 24,173 patients diagnosed with COPD and allied conditions between 2000 and 2013, and 24,170 selected matched patients without COPD comprised the comparison cohort from a nationwide database. Cox-proportional hazard regression was performed to determine the impact of medical therapies, comorbidities, and other clinical factors on stroke risk. Of the 48,343 included patients, 1394 (2.9%) experienced stroke during follow-up, with a significant difference between COPD and allied conditions cohort (1003/4.2%) and comparison cohort (391/1.6%) (adjusted hazard ratio [aHR]: 2.72, p < 0.001). Cox-regression analysis revealed that COPD and allied conditions patients who were older (>65 years) (HR: 1.06); male (HR: 1.39); with hypertension (HR: 1.46), diabetes mellitus (HR: 1.33) and atrial fibrillation (HR: 1.63) had increased stroke risk. Mucolytics (HR: 0.44) and combination therapy with inhaled corticosteroids (ICS) and long-acting β2-agonists (LABA) (HR: 0.75) were associated with decreased stroke risk in COPD and allied conditions patients. Among COPD and allied conditions patients, major comorbidities increase risk of stroke. Therapy with mucolytic agents and combination ICS/LABA is associated with risk reduction.
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9
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Chapman KR, Wise RA, Scirica BM, Bhatt DL, Daoud SZ, Lythgoe D, Gil EG. Long-acting antimuscarinic therapy in patients with chronic obstructive pulmonary disease receiving beta-blockers. Respir Res 2021; 22:272. [PMID: 34686204 PMCID: PMC8532273 DOI: 10.1186/s12931-021-01861-2] [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: 03/12/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Abstract
Background Beta-blocker therapies for cardiovascular comorbidities are often withheld in patients with chronic obstructive pulmonary disease (COPD) due to potential adverse effects on airway obstruction. We carried out a post hoc analysis to determine the efficacy and safety of aclidinium in patients with moderate-to-very severe COPD and increased cardiovascular risk receiving beta-blockers at baseline versus non-users. Methods ASCENT-COPD was a Phase 4, multicenter, double-blind, randomized, placebo-controlled, parallel-group study. Patients were randomized 1:1 to aclidinium or placebo twice-daily for up to 3 years. Outcomes included risk of (time to first) major adverse cardiovascular events (MACE), all-cause mortality, and lung function over 3 years, and exacerbations over 1 year. Results Of 3589 patients, 1269 (35.4%) used beta-blockers and 2320 (64.6%) were non-users at baseline. Aclidinium did not statistically increase the risk of MACE (beta-blocker user: hazard ratio 1.01 [95% CI 0.62–1.64]; non-user: 0.80 [0.51–1.24]; interaction P = 0.48) or all-cause mortality (beta-blocker user: 1.13 [0.78–1.64]; non-user: 0.89 [0.62–1.26]; interaction P = 0.35), in patients using beta-blockers. Aclidinium reduced annualized rate of moderate-to-severe COPD exacerbation (beta-blocker user: rate ratio 0.75 [95% CI 0.60–0.94, P = 0.013]; non-user: 0.79 [0.67–0.93, P = 0.005]), delayed time to first exacerbation, and improved lung function versus placebo. There was greater trough FEV1 benefit in beta-blocker users versus non-users (least squares mean difference at 52 weeks: 111 mL [95% CI 74 mL–147 mL] versus 69 mL [42 mL–97 mL]; interaction P = 0.041). Conclusions This post hoc analysis supports long-acting anti-muscarinic use with concomitant beta-blockers in patients with moderate-to-very severe COPD and cardiovascular comorbidity. Trial registration: ClinicalTrials.gov, NCT01966107, Registered 16 October 2013, https://clinicaltrials.gov/ct2/show/NCT01966107.
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Affiliation(s)
- Kenneth R Chapman
- Asthma and Airway Centre, University of Toronto, Toronto, ON, Canada. .,Asthma and Airway Centre, University Health Network, 7th Floor East Wing, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
| | - Robert A Wise
- Pulmonary Function Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin M Scirica
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sami Z Daoud
- Late-Stage Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
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10
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Wise RA, Scirica BM, Bhatt DL, Daoud SZ, Chuecos F, Garcia Gil E, Chapman KR. Efficacy of Aclidinium Bromide According to Baseline Therapy: Post-Hoc Analysis of ASCENT-COPD Randomized Trial. Adv Ther 2021; 38:5381-5397. [PMID: 34528220 PMCID: PMC8478777 DOI: 10.1007/s12325-021-01878-5] [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: 05/06/2021] [Accepted: 07/29/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Long-acting muscarinic antagonists (LAMAs), long-acting β2-agonists (LABAs), inhaled corticosteroids (ICS), and their combinations, are recommended for the treatment of chronic obstructive pulmonary disease (COPD). This study aimed to determine whether the safety and efficacy of aclidinium bromide differs by baseline maintenance LABA and ICS therapies. METHODS ASCENT-COPD was a phase 4, multicenter, double-blind, randomized, placebo-controlled, parallel-group study of patients with moderate-to-very severe COPD and increased cardiovascular risk. Patients were randomized 1:1 to receive aclidinium 400 μg or placebo twice daily, via a multidose dry-powder inhaler for up to 3 years. Outcomes included time to first major adverse cardiovascular events (MACE), all-cause mortality, change from baseline in trough forced expiratory volume in 1 s (FEV1), and COPD assessment test (CAT) total score over 3 years, and annual moderate-to-severe COPD exacerbation rate in patients receiving aclidinium or placebo with maintenance LABA monotherapy, ICS monotherapy, LABA + ICS (fixed/free), or no maintenance therapy (neither LABA nor ICS) at baseline. RESULTS A total of 3589 patients were included (LABA, n = 227; ICS, n = 290; LABA + ICS, n = 2058; no maintenance, n = 1130). Aclidinium did not increase the risk of MACE or all-cause mortality versus placebo, regardless of baseline maintenance treatment. Reductions in moderate-to-severe exacerbation rates were observed with aclidinium versus placebo in all subgroups [LABA 43% (P = 0.046); ICS 25% (P = 0.202); LABA + ICS 22% (P = 0.003); no maintenance 18% (P = 0.130)]. Aclidinium improved morning trough FEV1 irrespective of baseline therapy and CAT total scores, except for LABA and ICS subgroups, versus placebo at several time points. CONCLUSION In patients with moderate-to-severe COPD and CV risk factors, the addition of aclidinium to maintenance therapy with LABA or LABA + ICS provided further benefit. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01966107.
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Zhang C, Zhang M, Wang Y, Xiong H, Huang Q, Shuai T, Liu J. Efficacy and cardiovascular safety of LAMA in patients with COPD: a systematic review and meta-analysis. J Investig Med 2021; 69:1391-1398. [PMID: 34362778 PMCID: PMC8639957 DOI: 10.1136/jim-2021-001931] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is at present the third leading cause of death in the world. Long-acting muscarinic antagonist (LAMA) is widely used as a bronchodilator in patients with COPD. However, there is controversy concerning their cardiovascular safety. This meta-analysis aims to assess the efficacy and cardiovascular safety of LAMAs versus placebo in patients with COPD. We searched Pub Med, Embase, Cochrane Library, and Web of Science to identify studies that compared LAMA with placebo in patients with COPD. Twenty-one studies involving 24,987 participants were finally included in the analysis. There was no significant difference in the incidence of all adverse events (risk ratio (RR)=1.01, 95% CI 1.00 to 1.02, I2=15.2%) and cardiovascular events (RR=0.98, 95% CI 0.88 to 1.09, I2=4.9%) in patients treated with LAMAs versus placebo. LAMAs significantly improved trough forced expiratory volume in 1 s (weighted mean difference (WMD)=0.12, 95% CI 0.10 to 0.14, I2=86.6%), Transitional Dyspnea Index (WMD=0.75, 95% CI 0.56 to 0.94, I2=0%), and St. George's Respiratory Questionnaire (WMD=‒2.50, 95% CI ‒3.32 to ‒1.69, I2=39.8%). Moreover, LAMAs significantly reduced the incidence of exacerbation in patients with COPD (RR=0.85, 95% CI 0.79 to 0.91, I2=69.9%). LAMAs are safe therapy and play a pivotal role in improving lung function, dyspnea, and health status, and reducing the exacerbation in patients with COPD.
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Affiliation(s)
- Chuchu Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Meng Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Yalei Wang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Huaiyu Xiong
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Qiangru Huang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Tiankui Shuai
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Liu
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
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12
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D'Urzo AD, Singh D, Donohue JF, Chapman KR, Wise RA. Aclidinium bromide/formoterol fumarate as a treatment for COPD: an update. Expert Rev Respir Med 2021; 15:1093-1106. [PMID: 34137664 DOI: 10.1080/17476348.2021.1920403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Aclidinium/formoterol is a long-acting muscarinic antagonist (LAMA) and long-acting β2-agonist (LABA) dual bronchodilator used as a maintenance treatment for patients with chronic obstructive pulmonary disease (COPD). The efficacy of aclidinium/formoterol has been demonstrated consistently in patients with moderate-to-severe COPD versus placebo and monocomponents, with a comparable safety profile.Areas covered: This review examines recent research findings that expand our understanding of the impact of aclidinium/formoterol on the burden of COPD. Reviewed outcomes include improvements in lung function, respiratory symptoms, health-related quality of life, exercise tolerance, exacerbation rates, and clinically important deteriorations. In addition, the reported cardiovascular safety of aclidinium and current LAMA/LABA treatment recommendations are discussed.Expert opinion: Aclidinium/formoterol reduces disease burden in patients with COPD, including those that are treatment-naïve, without a significant increase in safety risk compared with monotherapies. Furthermore, evidence supports an improvement in lung function over a 24-hour period with aclidinium/formoterol treatment versus monotherapy and placebo, which may offer an advantage over some once-daily LAMA/LABA combinations. In summary, the recent evidence discussed in this review adds weight to the use of LAMA/LABA combinations as an initial therapy for certain patients newly diagnosed with COPD.
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Affiliation(s)
- Anthony D D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundations Trust, University of Manchester, Manchester, UK
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Pulmonary Critical Medicine, Chapel Hill, NC, USA
| | - Kenneth R Chapman
- Asthma and Airway Center, University Health Network, Toronto, ON, Canada
| | - Robert A Wise
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Cazzola M, Matera MG, Rogliani P, Calzetta L. Comparative studies of dual bronchodilation in COPD. Monaldi Arch Chest Dis 2021; 91. [PMID: 33586398 DOI: 10.4081/monaldi.2021.1625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 12/11/2020] [Indexed: 11/23/2022] Open
Abstract
Dual bronchodilation therapy is becoming the cornerstone for the treatment of COPD because the clinical benefits of LABA/LAMA fixed-dose combinations (FDCs) are now extensively established. Therefore, it not surprising that a number of LAMA/LABA combinations in a single inhaler have now been approved for clinical use as treatments for patients with COPD. Regrettably, very few head-to-head studies between all of the available LABA/LAMA FDCs have been carried out. This makes choosing the most appropriate FDC difficult. Comparative effectiveness research that also uses conventional meta-analyses to compare different care strategies can help generate useful information. A bidimensional comparative analysis across LAMA/LABA FDCs has suggested constant superiority for tiotropium/olodaterol. However, considering that there is not an equivalent amount of evidence on efficacy outcomes for all LAMA/LABA FDCs, a proper comparison between the different LAMA/LABA FDCs cannot be made yet, and the information available is still rather inconsistent.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome.
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples.
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome.
| | - Luigino Calzetta
- Unit of Respiratory Disease and Lung Function, Department of Medicine and Surgery, University of Parma.
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14
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Andreas S, Bothner U, de la Hoz A, Kloer I, Trampisch M, Alter P. No Influence on Cardiac Arrhythmia or Heart Rate from Long-Term Treatment with Tiotropium/Olodaterol versus Monocomponents by Holter ECG Analysis in Patients with Moderate-to-Very-Severe COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:1945-1953. [PMID: 32848380 PMCID: PMC7429402 DOI: 10.2147/copd.s246350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) and cardiovascular comorbidities may have an increased risk of medication-related cardiac arrhythmias. We therefore performed an analysis of Holter electrocardiogram (ECG) data from two large, long-term, controlled clinical COPD trials to investigate whether tiotropium/olodaterol increased the risk of cardiac arrhythmia and mean heart rate. Methods We analyzed Holter ECG data from a representative subset of patients (N=506) from the two pooled replicate studies (TONADO 1 and 2) assessing tiotropium/olodaterol 5/5 µg therapy versus tiotropium 5 µg or olodaterol 5 µg monotherapy, inhaled once daily (two single inhalations) using the Respimat® Soft Mist™ inhaler device. Additionally, major adverse cardiac events (MACE) with tiotropium/olodaterol were assessed versus the respective monotherapies. Results After 12 weeks of treatment, there was no difference in the number of patients who had an increase or decrease from baseline in 24-hour supraventricular premature beats or ventricular premature beats between tiotropium/olodaterol 5/5 µg combination therapy and its monocomponents. Compared with baseline, a small but statistically significant increase in adjusted mean heart rate was observed for tiotropium 5 µg (+1.6 beats per minute [bpm]; P=0.0010), but no difference was observed for olodaterol 5 µg (+0.3 bpm; P=0.2778) or tiotropium/olodaterol 5/5 µg (-0.1 bpm; P=0.4607). MACE and fatal MACE were limited to 1 to 3 patients across treatment groups. Conclusion Compared with the compounds given as monotherapy, treatment with tiotropium/olodaterol fixed-dose combination therapy is not associated with medically relevant or statistically significant effects on arrhythmia as assessed by Holter ECG. Based on these findings, there is no evidence to assume a clinically relevant impact on cardiac function from dual tiotropium/olodaterol treatment. Trial Registration TONADO 1 (ClinicalTrials.gov: NCT01431274); TONADO 2 (ClinicalTrials.gov: NCT01431287).
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Affiliation(s)
- Stefan Andreas
- Department of Cardiology and Pneumology, University Medical Centre Göttingen, Göttingen, Germany
- LungClinic Immenhausen, Immenhausen, Germany, Member of the German Center for Lung Research (DZL)
| | - Ulrich Bothner
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Isabel Kloer
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Marburg, Germany, Member of the German Center for Lung Research (DZL)
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15
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Andreas S. <p>Effects of LAMA/LABA Alone and in Combination on Cardiac Safety</p>. Int J Chron Obstruct Pulmon Dis 2020; 15:1931-1933. [PMID: 36211534 PMCID: PMC9536198 DOI: 10.2147/copd.s246356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Stefan Andreas
- Department of Cardiology and Pneumology, University Medical Centre Göttingen, Göttingen, Germany
- LungClinic Immenhausen, Immenhausen, Germany, Member of the German Center for Lung Research (DZL)
- Correspondence: Stefan Andreas Department of Cardiology and Pneumology, Herzzentrum Gottingen, Robert-Koch-Str. 40, Göttingen, GermanyTel +49 05673 501 1112Fax +49 05673-501-1101 Email
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16
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Anzueto A, Miravitlles M. Tiotropium in chronic obstructive pulmonary disease - a review of clinical development. Respir Res 2020; 21:199. [PMID: 32727455 PMCID: PMC7389564 DOI: 10.1186/s12931-020-01407-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background Bronchodilators are the mainstay of pharmacological treatment in chronic obstructive pulmonary disease (COPD), and long-acting muscarinic antagonist (LAMA) monotherapy is recommended as initial treatment for Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, and D. Main body Tiotropium bromide was the first LAMA available for COPD in clinical practice and, because of its long duration of action, is administered once daily. Tiotropium was initially available as an inhalation powder delivered via a dry-powder inhaler (DPI). Later, tiotropium also became available as an inhalation spray delivered via a soft mist inhaler (SMI). The SMI was designed to overcome or minimize some of the issues associated with other inhaler types (eg, the need for strong inspiratory airflow with DPIs). Results of short- and long-term randomized, controlled clinical trials of tiotropium in patients with COPD indicated tiotropium was safe and significantly improved lung function, health-related quality of life, and exercise endurance, and reduced dyspnea, lung hyperinflation, exacerbations, and use of rescue medication compared with placebo or active comparators. These positive efficacy findings triggered the evaluation of tiotropium in fixed-dose combination with olodaterol (a long-acting β2-agonist). In this review, we provide an overview of studies of tiotropium for the treatment of COPD, with a focus on pivotal studies. Conclusion Tiotropium is safe and efficacious as a long-term, once-daily LAMA for the maintenance treatment of COPD and for reducing COPD exacerbations. The SMI generates a low-velocity, long-duration aerosol spray with a high fine-particle fraction, which results in marked lung drug deposition. In addition, high inspiratory flow rates are not required.
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Affiliation(s)
- Antonio Anzueto
- Internal Medicine, Pulmonary Disease, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitary Vall d'Hebron/Vall d'Hebron Research Institute (VHIR). CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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17
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Fischer O, Hofmann J, Rampp H, Kaindl J, Pratsch G, Bartuschat A, Taudte RV, Fromm MF, Hübner H, Gmeiner P, Heinrich MR. Regiospecific Introduction of Halogens on the 2-Aminobiphenyl Subunit Leading to Highly Potent and Selective M3 Muscarinic Acetylcholine Receptor Antagonists and Weak Inverse Agonists. J Med Chem 2020; 63:4349-4369. [PMID: 32202101 DOI: 10.1021/acs.jmedchem.0c00297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Muscarinic M3 receptor antagonists and inverse agonists displaying high affinity and subtype selectivity over the antitarget M2 are valuable pharmacological tools and may enable improved treatment of chronic obstructive pulmonary disease (COPD), asthma, or urinary incontinence. On the basis of known M3 antagonists comprising a piperidine or quinuclidine unit attached to a biphenyl carbamate, 5-fluoro substitution was responsible for M3 subtype selectivity over M2, while 3'-chloro substitution substantially increased affinity through a σ-hole interaction. Resultantly, two piperidinyl- and two quinuclidinium-substituted biphenyl carbamates OFH243 (13n), OFH244 (13m), OFH3911 (14n), and OFH3912 (14m) were discovered, which display two-digit picomolar affinities with Ki values from 0.069 to 0.084 nM, as well as high selectivity over the M2 subtype (46- to 68-fold). While weak inverse agonistic properties were determined for the biphenyl carbamates 13m and 13n, neutral antagonism was observed for 14m and 14n and tiotropium under identical assay conditions.
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Affiliation(s)
- Oliver Fischer
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Josefa Hofmann
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Hannelore Rampp
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Jonas Kaindl
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Gerald Pratsch
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Amelie Bartuschat
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - R Verena Taudte
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Fahrstr. 17, 91054 Erlangen, Germany
| | - Martin F Fromm
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Fahrstr. 17, 91054 Erlangen, Germany
| | - Harald Hübner
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Peter Gmeiner
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Markus R Heinrich
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
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18
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Chen YF, Cheng YC, Chou CH, Chen CY, Yu CJ. Major comorbidities lead to the risk of adverse cardiovascular events in chronic obstructive pulmonary disease patients using inhaled long-acting bronchodilators: a case-control study. BMC Pulm Med 2019; 19:233. [PMID: 31795986 PMCID: PMC6889444 DOI: 10.1186/s12890-019-0999-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND While inhaled bronchodilators reduce symptoms and acute exacerbations of chronic obstructive pulmonary disease (COPD), their use is associated with increased cardiovascular events in some studies. This study investigates the risk of adverse events associated with the use of inhaled bronchodilators in COPD patients with multimorbidity. METHODS A case-control study was conducted between January 2015 and December 2017, and patients with spirometry-confirmed diagnosis of COPD (N = 1565) using inhaled long-acting bronchodilators were enrolled. Medical records were reviewed and clinical data, including age, gender, smoking status, major comorbidities, lung function stage, history of exacerbations, bronchodilator regimens, and treatment duration were analyzed. Major adverse cardiovascular events occurring during long-acting bronchodilator use were recorded. RESULTS The most common comorbidities were cardiovascular disease (CVD) (53.6%) and chronic kidney disease (CKD) (25.8%). We observed that CVD (odds ratio [OR], 5.77), CKD (OR, 2.02) and history of frequent exacerbations (OR, 2.37) were independent risk factors for cardiovascular events, regardless of the type of bronchodilators use. Moreover, COPD patients with both CKD and CVD had higher risk (6.32-fold) of adverse cardiovascular effects than those with neither comorbidity. Eighty-seven of 1565 (5.56%) COPD patients died during this study period. Of them, 21.8% (19/87) were cardiovascular-related and 73.6% (64/87) patients were respiratory-related mortality. Among COPD patients using long-acting bronchodilators, CKD was the only risk factor to predict cardiovascular events and cardiovascular-related mortality (OR, 4.87; 95% confidence interval [CI], 1.75-13.55]. CONCLUSIONS COPD patients had higher risk of cardiovascular events were associated with their CVD and/or CKD comorbidities and history of frequent exacerbations, rather than associated with their use of inhaled bronchodilators.
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Affiliation(s)
- Yen-Fu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, No.579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County, 640, Taiwan, Republic of China
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ching Cheng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, No.579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County, 640, Taiwan, Republic of China
| | - Chien-Hong Chou
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, No.579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County, 640, Taiwan, Republic of China
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chung-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, No.579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County, 640, Taiwan, Republic of China.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Chong-Jen Yu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei, Taiwan
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Cassambai S, Mee CJ, Renshaw D, Hussain A. Tiotropium bromide, a long acting muscarinic receptor antagonist triggers intracellular calcium signalling in the heart. Toxicol Appl Pharmacol 2019; 384:114778. [DOI: 10.1016/j.taap.2019.114778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/14/2019] [Accepted: 10/06/2019] [Indexed: 12/30/2022]
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20
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Donohue JF, Feldman G, Sethi S, Barnes CN, Pendyala S, Bourdet D, Crater G. Cardiovascular safety of revefenacin, a once-daily, lung-selective, long-acting muscarinic antagonist for nebulized therapy of chronic obstructive pulmonary disease: Evaluation in phase 3 clinical trials. Pulm Pharmacol Ther 2019; 57:101808. [PMID: 31152911 DOI: 10.1016/j.pupt.2019.101808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/12/2019] [Accepted: 05/24/2019] [Indexed: 01/01/2023]
Abstract
The cardiovascular safety of revefenacin, an anticholinergic indicated for the maintenance treatment of patients with chronic obstructive lung disease (COPD), was evaluated in phase 3 trials in patients with moderate to very severe COPD. No clinically meaningful changes in 12-lead electrocardiogram recordings were observed with up to 52 weeks of once-daily revefenacin 88 or 175 μg. In a pooled analysis of Studies 0126 and 0127, the incidence of prolonged QT interval corrected for heart rate using the Fridericia correction formula (QTcF; >450 msec) for revefenacin 88 μg (n = 23, 5.6%) and revefenacin 175 μg (n = 23, 5.9%) was similar to that for placebo (n = 22, 5.3%). In Study 0128, the incidence of prolonged QTcF was similar in the revefenacin 175 μg (n = 25, 7.7%) and tiotropium (n = 26, 7.3%) groups and lower in the revefenacin 88 μg (n = 15, 4.2%) group. There were four major adverse cardiac events (MACEs) in Study 0126 (one, two, and one in the placebo, revefenacin 88 μg, and revefenacin 175 μg groups, respectively), no MACEs in Study 0127 and 26 MACEs in Study 0128 (9, 10 and 7 in the revefenacin 88 μg, revefenacin 175 μg and tiotropium groups, respectively). In Study 0128, only one MACE was considered possibly/probably related to revefenacin (atrial fibrillation in the revefenacin 175 μg group). Thus, revefenacin may provide beneficial nebulized therapy for patients with COPD without further elevating their risk of cardiovascular events.
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Affiliation(s)
- James F Donohue
- UNC School of Medicine, 130 Mason Farm Road, Chapel Hill, NC, 27514, USA.
| | - Gregory Feldman
- South Carolina Pharmaceutical Research, 151 Harold Fleming Court, Spartanburg, SC, 29303, USA.
| | - Sanjay Sethi
- University at Buffalo, State University of New York, 3495 Bailey Avenue, Buffalo, NY, 14215, USA.
| | - Chris N Barnes
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
| | - Srikanth Pendyala
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
| | - David Bourdet
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
| | - Glenn Crater
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
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21
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Wise RA, Chapman KR, Scirica BM, Bhatt DL, Daoud SZ, Zetterstrand S, Reisner C, Gil EG. Effect of Aclidinium Bromide on Major Cardiovascular Events and Exacerbations in High-Risk Patients With Chronic Obstructive Pulmonary Disease: The ASCENT-COPD Randomized Clinical Trial. JAMA 2019; 321:1693-1701. [PMID: 31063575 PMCID: PMC6506885 DOI: 10.1001/jama.2019.4973] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 04/08/2019] [Indexed: 12/23/2022]
Abstract
Importance There is concern that long-acting muscarinic antagonists increase cardiovascular morbidity or mortality in patients with chronic obstructive pulmonary disease (COPD). Objective To determine the cardiovascular safety (noninferiority) and efficacy (superiority) of aclidinium bromide, 400 μg twice daily, in patients with COPD and cardiovascular disease or risk factors. Design, Setting, and Participants Multicenter, randomized, placebo-controlled, double-blind, parallel-design study conducted at 522 sites in North America. A total of 3630 patients with moderate to very severe COPD and either a history of cardiovascular disease or at least 2 atherothrombotic risk factors were randomized; follow-up occurred for up to 3 years until at least 122 major adverse cardiovascular events (MACE) occurred. The first patient was enrolled on October 16, 2013 and the last on August 22, 2016. The final patient completed follow-up on September 21, 2017. Interventions Patients were randomized to receive aclidinium (n = 1812) or placebo (n = 1818) by dry-powder inhaler, twice daily for up to 3 years. Main Outcomes and Measures The primary safety end point was time to first MACE over up to 3 years (hazard ratio [HR] 1-sided 97.5% CI noninferiority margin = 1.8). The primary efficacy end point was the annual COPD exacerbation rate during the first year of treatment. Secondary outcomes included an expanded MACE definition (time to first MACE or serious cardiovascular event of interest) and annual rate of exacerbations requiring hospitalization. Results Among 3589 patients analyzed (mean age, 67.2 years; 58.7% male), 2537 (70.7%) completed the study. Of these, 69 (3.9%) aclidinium and 76 (4.2%) placebo patients had a MACE (HR, 0.89; 1-sided 97.5% CI, 0-1.23); the expanded MACE definition included 168 (9.4%) aclidinium vs 160 (8.9%) placebo patients with events (HR, 1.03; 1-sided 97.5% CI, 0-1.28). Annual moderate to severe exacerbation rates (aclidinium, 0.44; placebo, 0.57; rate ratio, 0.78; 2-sided 95% CI, 0.68-0.89; P < .001) and rate of exacerbations requiring hospitalization (aclidinium, 0.07; placebo, 0.10; rate ratio, 0.65; 2-sided 95% CI, 0.48-0.89; P = .006) decreased significantly with aclidinium vs placebo. The most common adverse events were pneumonia (aclidinium, 109 events [6.1%]; placebo, 105 events [5.8%]), urinary tract infection (aclidinium, 93 events [5.2%]; placebo, 89 events [5.0%]), and upper respiratory tract infection (aclidinium, 86 events [4.8%]; placebo, 101 events [5.6%]). Conclusions and Relevance Among patients with COPD and increased cardiovascular risk, aclidinium was noninferior to placebo for risk of MACE over 3 years. The rate of moderate to severe COPD exacerbations was reduced over the first year. Trial Registration ClinicalTrials.gov Identifier: NCT01966107.
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Affiliation(s)
- Robert A. Wise
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Benjamin M. Scirica
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sami Z. Daoud
- AstraZeneca Research and Development Centre, Gaithersburg, Maryland
| | - Sofia Zetterstrand
- AstraZeneca Research and Development, Bioinformatics and Information Sciences, Mölndal, Sweden
| | - Colin Reisner
- AstraZeneca Research and Development Centre, Gaithersburg, Maryland
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Carter P, Lagan J, Fortune C, Bhatt DL, Vestbo J, Niven R, Chaudhuri N, Schelbert EB, Potluri R, Miller CA. Association of Cardiovascular Disease With Respiratory Disease. J Am Coll Cardiol 2019; 73:2166-2177. [PMID: 30846341 DOI: 10.1016/j.jacc.2018.11.063] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/08/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The relationship between respiratory diseases and individual cardiovascular diseases, and the impact of cardiovascular diseases on mortality in patients with respiratory disease, are unclear. OBJECTIVES This study sought to determine the relationship between chronic obstructive pulmonary disease (COPD), asthma and interstitial lung disease (ILD), and individual cardiovascular diseases, and evaluate the impact of individual cardiovascular diseases on all-cause mortality in respiratory conditions. METHODS The authors conducted a cohort study of all patients admitted to 7 National Health Service hospitals across the North West of England, between January 1, 2000, and March 31, 2013, with relevant respiratory diagnoses, with age-matched and sex-matched control groups. RESULTS A total of 31,646 COPD, 60,424 asthma, and 1,662 ILD patients were included. Control groups comprised 158,230, 302,120, and 8,310 patients, respectively (total follow-up 2,968,182 patient-years). COPD was independently associated with ischemic heart disease (IHD), heart failure (HF), atrial fibrillation, and peripheral vascular disease, all of which were associated with all-cause mortality (e.g., odds ratio for the association of COPD with HF: 2.18 [95% confidence interval (CI): 2.08 to 2.26]; hazard ratio for the contribution of HF to mortality in COPD: 1.65 [95% CI: 1.61 to 1.68]). Asthma was independently associated with IHD, and multiple cardiovascular diseases contributed to mortality (e.g., HF hazard ratio: 1.81 [95% CI: 1.75 to 1.87]). ILD was independently associated with IHD and HF, both of which were associated with mortality. Patients with lung disease were less likely to receive coronary revascularization. CONCLUSIONS Lung disease is independently associated with cardiovascular diseases, particularly IHD and HF, which contribute significantly to all-cause mortality. However, patients with lung disease are less likely to receive coronary revascularization.
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Affiliation(s)
- Paul Carter
- ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, United Kingdom; Cambridge Cardiovascular Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Jakub Lagan
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom; Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Christien Fortune
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DLBHATTMD
| | - Jørgen Vestbo
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Robert Niven
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Nazia Chaudhuri
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; UPMC Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania; Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rahul Potluri
- ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, United Kingdom
| | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom; Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Wellcome Centre for Cell-Matrix Research, Division of Cell-Matrix Biology & Regenerative Medicine, School of Biology, Faculty of Biology, Medicine & Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.
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Harrison EM, Kim V. Long-acting maintenance pharmacotherapy in chronic obstructive pulmonary disease. RESPIRATORY MEDICINE: X 2019. [DOI: 10.1016/j.yrmex.2019.100009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Liou JT, Lin CW, Tsai CL, Wang YH, Lai JH, Hsu YJ, Wang MT. Risk of Severe Cardiovascular Events From Add-On Tiotropium in Chronic Obstructive Pulmonary Disease. Mayo Clin Proc 2018; 93:1462-1473. [PMID: 30104044 DOI: 10.1016/j.mayocp.2018.05.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/28/2018] [Accepted: 05/07/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To examine the risk of cardiovascular disease (CVD) from tiotropium added to inhaled long-acting β2 agonists (LABAs) and inhaled corticosteroids (ICSs) in a nationwide population with chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS This nested case-control study included 65,966 patients with COPD treated with LABAs and ICSs identified from the Taiwan nationwide health care claims database from January 1, 2007, through June 30, 2011. Cases were all patients with a first primary diagnosis of ischemic heart disease, heart failure, stroke, or arrhythmia from inpatient or emergency care settings during follow-up, and each was matched with 4 disease risk score-matched controls from risk sets. The use of tiotropium in the year before the index/event date was measured, stratified by duration since therapy initiation, concomitant COPD medications, and dosage form. Conditional logistic regression models were used to estimate odds ratios of the CVD risk from add-on tiotropium therapy. RESULTS From the study cohort, with a mean age of 70.3 years (interquartile range, 61.8-79.4 years), 3188 CVD cases (incidence rate, 6.2 [95% CI, 6.0-6.4] cases per 100 person-years) and 12,349 matched controls were identified. The new use of tiotropium was associated with a 1.88-fold (95% CI, 1.44-2.46) increased CVD risk within 30 days of therapy initiation, and the association was sustained up to 60 days after treatment initiation (adjusted odds ratio, 1.71; 95% CI, 1.08-2.70). The risk persisted across all tiotropium regimens, with a case-crossover analysis, and in comparison with new add-on theophylline therapy. CONCLUSION Tiotropium newly added to LABA/ICS combination therapy was associated with an increased cardiovascular risk in patients with COPD.
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Affiliation(s)
- Jun-Ting Liou
- Division of Cardiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chen Wei Lin
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chen-Liang Tsai
- Division of Pulmonary and Critical Care, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yun-Han Wang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Jyun-Heng Lai
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China; Graduate Institutes of Medical Sciences and Biochemistry, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Meng-Ting Wang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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Liu Z, Shi F, Liu J, Gao C, Pei M, Li J, Li P. Effect of the emphysema subtypes of patients with chronic obstructive pulmonary disease on airway inflammation and COTE index. Exp Ther Med 2018; 16:4745-4752. [DOI: 10.3892/etm.2018.6799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 07/13/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Zheng Liu
- Department of Respiratory Tract Medicine, The Petroleum Clinical Medical College of Hebei Medical University, Langfang, Hebei 065000, P.R. China
| | - Fang Shi
- Department of Respiratory Tract Medicine, The Petroleum Clinical Medical College of Hebei Medical University, Langfang, Hebei 065000, P.R. China
| | - Jun‑Xia Liu
- Department of Respiratory Tract Medicine, The Petroleum Clinical Medical College of Hebei Medical University, Langfang, Hebei 065000, P.R. China
| | - Chang‑Lan Gao
- Department of Respiratory Tract Medicine, The Petroleum Clinical Medical College of Hebei Medical University, Langfang, Hebei 065000, P.R. China
| | - Meng‑Miao Pei
- Department of Respiratory Tract Medicine, The Petroleum Clinical Medical College of Hebei Medical University, Langfang, Hebei 065000, P.R. China
| | - Jing Li
- Department of Respiratory Tract Medicine, The Petroleum Clinical Medical College of Hebei Medical University, Langfang, Hebei 065000, P.R. China
| | - Pei‑Xiu Li
- Department of Radiology, The Petroleum Clinical Medical College of Hebei Medical University, Langfang, Hebei 065000, P.R. China
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The Impact of Care Specialty on Survival-Adjusted Medical Costs of COPD Patients After a Hospitalization: a longitudinal analysis. J Gen Intern Med 2018; 33:1528-1535. [PMID: 29611088 PMCID: PMC6109016 DOI: 10.1007/s11606-018-4406-x] [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: 07/11/2017] [Revised: 12/08/2017] [Accepted: 03/08/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Little is known about the impact of care provider's specialty on the medical costs of COPD patients over time. OBJECTIVE To compare the long-term medical costs between newly hospitalized COPD patients whose post-discharge care was initiated by a pulmonary specialist versus by a general practitioner. DESIGN Retrospective matched cohort study. PARTICIPANTS We identified patients with an incident COPD-related hospitalization from the administrative health database (January 1, 1996, to December 31, 2012) of British Columbia, Canada. MAIN MEASURES Patients were categorized as receiving specialist care or primary care within the first 90 days after discharge from an incident COPD-related hospitalization. Using propensity scores, we matched each patient who initially received specialist care to a patient who received primary care based on demographics, COPD severity, comorbidity, and admission time. A survival-adjusted, multi-part generalized linear model was used to estimate direct medical costs (in 2015 Canadian dollars, [$], including inpatient, outpatient, pharmacy, and community care costs) as overall and as COPD-specific and comorbidity-related costs over the following 5 years. KEY RESULTS The sample included 7710 patients under each group. The initial specialist-care recipients had a modestly higher 5-year survival than the generalist-care recipients (0.564 [95% CI 0.535, 0.634] vs 0.555 [95% CI 0.525, 0.625]; P < .001). Meanwhile, the former incurred $2809 higher all-cause medical costs over 5 years compared to the latter (95% CI $2343, $2913; P < .001), mainly driven by higher medication costs (difference $1782 [95% CI $1658, $1830]; P < .001) particularly related to COPD medications ($1170 [95% CI $1043, $1225]; P < .001). Specialist care recipients also incurred higher costs of COPD-related hospitalization ($1144 [95% CI $650, $1221]; P < .001). CONCLUSIONS Compared to generalist care, specialist care following COPD hospitalization is slightly more expensive, mainly driven by medication costs especially COPD-specific medications. Future studies should compare differences in health-related quality of life and COPD functional status.
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Wise RA, Chapman KR, Scirica BM, Schoenfeld DA, Bhatt DL, Daoud SZ, Seoane B, Reisner C, Garcia Gil E. Long-Term Evaluation of the Effects of Aclidinium Bromide on Major Adverse Cardiovascular Events and COPD Exacerbations in Patients with Moderate to Very Severe COPD: Rationale and Design of the ASCENT COPD Study. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2018; 5:5-15. [PMID: 29629400 PMCID: PMC5870740 DOI: 10.15326/jcopdf.5.1.2017.0149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 01/21/2023]
Abstract
Introduction: Chronic obstructive pulmonary disease (COPD) is a heterogeneous illness characterized by persistent airflow obstruction and exacerbations. Patients typically experience a decline in lung function, increasingly impaired health-related quality of life, and high mortality. Poor lung function and exacerbations are associated with an increased risk of cardiovascular (CV) and cerebrovascular events, and approximately 30% of patients with COPD die from CV‑related disease. Treatment with inhaled long-acting bronchodilators, such as long-acting muscarinic antagonists (LAMAs), is recommended; however, some studies have suggested that LAMAs may increase the risk of CV events. As patients with CV and cerebrovascular conditions are often excluded from clinical trials, an evaluation of the safety of COPD treatments in an at-risk population is vital. Aclidinium bromide is a LAMA approved for the long-term maintenance treatment of COPD. Methods and Objectives: The Phase 4, multicenter, double-blind, randomized, placebo-controlled, parallel-group Aclidinium Bromide on Long-Term Cardiovascular Safety and COPD Exacerbations in PatieNTs with Moderate to Very Severe COPD (ASCENT COPD) study (NCT01966107) is being conducted at 500 sites in the United States and Canada. The primary objectives are to evaluate the long-term effects of twice-daily aclidinium bromide 400 µg on CV safety and exacerbations in patients with moderate to very severe COPD with a history of cerebrovascular, coronary, or peripheral artery disease, or the presence of ≥2 atherothrombotic risk factors. The primary safety and efficacy variables are time to first major adverse CV event (MACE) (on-study analysis) and rate of moderate to severe COPD exacerbations during the first year of treatment (on-treatment analysis), respectively. The study will be terminated after approximately 122 MACE have occurred.
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Affiliation(s)
- Robert A. Wise
- 1-Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Benjamin M. Scirica
- 3-Brigham and Women’s Hospital, Boston, Massachusetts
- 4-Harvard Medical School, Boston, Massachusetts
| | | | - Deepak L. Bhatt
- 3-Brigham and Women’s Hospital, Boston, Massachusetts
- 4-Harvard Medical School, Boston, Massachusetts
| | - Sami Z. Daoud
- 5-AstraZeneca Research &Development Center, Gaithersburg, Maryland
| | - Beatriz Seoane
- 6-AstraZeneca Research & Development Centre, Barcelona, Spain
| | - Colin Reisner
- 5-AstraZeneca Research &Development Center, Gaithersburg, Maryland
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Tiotropium for the Treatment of Asthma: Patient Selection and Perspectives. Can Respir J 2018; 2018:3464960. [PMID: 29670674 PMCID: PMC5833870 DOI: 10.1155/2018/3464960] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/13/2017] [Indexed: 11/17/2022] Open
Abstract
Asthma is a chronic disease of airway inflammation with a large global burden. Despite established, guideline-based stepwise therapy, a significant proportion of patients remain symptomatic and poorly controlled. As such, there is a need for additional safe, effective, convenient, and cost-effective therapies that can be broadly applied across a range of asthma phenotypes. Tiotropium is a long-acting muscarinic antagonist (LAMA) that leads to bronchodilation by blocking endogenous acetylcholine receptors in the airways. Tiotropium has long been approved for the treatment of chronic obstructive pulmonary disease, and it has recently been recognized for its safety and efficacy in improving lung function and controlling asthma. Evidence from several Phase III trials in the adult and paediatric population has shown that tiotropium is well tolerated and significantly improves a range of endpoints as an add-on treatment to ICS therapy, regardless of baseline characteristics and clinical phenotypes. Consequently, regulatory authorities worldwide have recently licensed tiotropium as the only LAMA approved for the treatment of asthma. This review provides an overview of safety and efficacy data and discusses the use of tiotropium in patients across the range of asthma severities, ages, and phenotypes.
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Lee CH, Choi S, Jang EJ, Yang HM, Il Yoon H, Kim YJ, Kim J, Yim JJ, Kim DK. Inhaled bronchodilators and acute myocardial infarction: a nested case-control study. Sci Rep 2017; 7:17915. [PMID: 29263396 PMCID: PMC5738390 DOI: 10.1038/s41598-017-17890-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/01/2017] [Indexed: 11/17/2022] Open
Abstract
We investigated the association between the use of inhaled bronchodilators and the risk of AMI. A nested case-control study using the nationwide insurance claims database was conducted. Overall, 11,054 AMI cases and 47,815 matched (up to 1:5) controls were identified from 1,036,119 subjects without acute major cardiovascular events in the past year. Long-acting and short-acting β-agonists (LABAs and SABAs) were associated with increase in the risk of AMI, although an inhaled corticosteroid combined with a long-acting β-agonist was not. Long-acting muscarinic antagonists (LAMAs) in a dry powder inhaler (DPI) were significantly associated with reduced risk of AMI, while LAMAs in a soft mist inhaler (SMI) didn't decrease the risk of it. In hypertensive or diabetic patients, LAMAs in a DPI were associated with reduced risk of AMI, but LABAs were associated with increased risk. Among the β-blocker users, the reduction of AMI risk by LAMAs was the most significant. In conclusions, inhaled β-agonists were associated with increase in the risk of AMI, while LABAs accompanied by ICSs were not associated with increase in the risk of AMI. LAMAs in a DPI use were associated with lower risk of AMI.
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Affiliation(s)
- Chang-Hoon Lee
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Seongmi Choi
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Department of Statistics, College of Natural Sciences, Kyungpook National University, 80 Daehakro, Buk-Gu, Daegu, 41566, Republic of Korea
| | - Eun Jin Jang
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Department of Information Statistics, Colloge of Natural Science, Andong National University, 1375 Gyeongdong-Ro, Andong, 36729, Republic of Korea
| | - Han-Mo Yang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Ho Il Yoon
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-Ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Yun Jung Kim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
| | - Jimin Kim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Jae-Joon Yim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Deog Kyeom Kim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-Ro 5-Gil, Dongjak-Gu, Seoul, 07061, Republic of Korea.
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Lal C, Strange C. A review of current and developing fixed-dose LABA/LAMA combinations for treating COPD. Expert Opin Pharmacother 2017; 18:1833-1843. [PMID: 29115881 DOI: 10.1080/14656566.2017.1403583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The current GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommendations suggest using long acting β2 agonists (LABA) and long acting muscarinic antagonists (LAMA) in combination for group B COPD patients with persistent symptoms, group C COPD patients with further exacerbations on LAMA therapy alone and for group D COPD patients with or without combination with inhaled corticosteroids (ICS). Thus, there is a lot of interest in developing LABA/LAMA combinations for maintenance therapy of chronic stable COPD. Areas covered: Many LABA/LAMA combinations have successfully been approved through carefully designed pivotal clinical trials. The current clinical use of LABA/LAMA combinations in COPD will continue to evolve as new trials with and without inhaled corticosteroids are completed. Expert opinion: Combining different classes of bronchodilators in a single inhaler is an attractive concept that can potentially improve patient adherence to therapy. Because LABA/LAMA combinations are the preferred treatment option for preventing COPD exacerbations in the updated GOLD guidelines for COPD, they will be clinically used. Future treatment of COPD should revolve around a personalized approach based on characterization of the COPD phenotype.
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Affiliation(s)
- Chitra Lal
- a Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
| | - Charlie Strange
- a Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
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Castiglia D, Battaglia S, Benfante A, Sorino C, Scichilone N. Pharmacological Management of Elderly Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome: Room for Speculation? Drugs Aging 2017; 33:375-85. [PMID: 27138954 DOI: 10.1007/s40266-016-0368-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are two distinct diseases that share a condition of chronic inflammation of the airways and bronchial obstruction. In clinical settings, it is not rare to come across patients who present with clinical and functional features of both diseases, posing a diagnostic dilemma. The overlap condition has been termed asthma-COPD overlap syndrome (ACOS), and mainly occurs in individuals with long-standing asthma, especially if they are also current or former smokers. Patients with ACOS have poorer health-related quality of life and a higher exacerbation rate than subjects with asthma or COPD alone. Whether ACOS is a distinct nosological entity with genetic variants or rather a condition of concomitant diseases that overlap is still a matter of debate. However, there is no doubt that extended life expectancy has increased the prevalence of asthma and COPD in older ages, and thus the probability that overlap conditions occur in clinical settings. In addition, age-associated changes of the lung create the basis for the two entities to converge on the same subject. ACOS patients may benefit from a stepwise treatment similar to that of asthma and COPD; however, the proposed therapeutic algorithms are only speculative and extrapolated from studies that are not representative of the ACOS population. Inhaled corticosteroids are the mainstay of therapy, and always in conjunction with long-acting bronchodilators. The potential heterogeneity of the overlap syndrome in terms of inflammatory features (T helper-1 vs. T helper-2 pathways) may be responsible for the different responses to treatments. The interaction between respiratory drugs and concomitant diseases should be carefully evaluated. Similarly, the effect of non-respiratory drugs, such as aspirin, statins, and β-blockers, on lung function needs to be properly assessed.
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Affiliation(s)
- Daniela Castiglia
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.MIS), University of Palermo, via Trabucco 180, 90146, Palermo, Italy
| | - Salvatore Battaglia
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.MIS), University of Palermo, via Trabucco 180, 90146, Palermo, Italy
| | - Alida Benfante
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.MIS), University of Palermo, via Trabucco 180, 90146, Palermo, Italy
| | | | - Nicola Scichilone
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.MIS), University of Palermo, via Trabucco 180, 90146, Palermo, Italy. .,Istituto Euro-Mediterraneo di Scienza e Tecnologia, Palermo, Italy.
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Samp JC, Joo MJ, Schumock GT, Calip GS, Pickard AS, Lee TA. Risk of Cardiovascular and Cerebrovascular Events in COPD Patients Treated With Long-Acting β 2-Agonist Combined With a Long-Acting Muscarinic or Inhaled Corticosteroid. Ann Pharmacother 2017; 51:945-953. [PMID: 28677404 DOI: 10.1177/1060028017719716] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The recent approval of several fixed-dose combination long-acting β2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) products has increased the use of dual bronchodilators in the treatment of chronic obstructive pulmonary disease (COPD). Understanding the comparative safety of this combination is important for informing treatment decisions. OBJECTIVE To compare the risk of cardiovascular and cerebrovascular (CCV) events associated with LABA/LAMA compared with a combination of LABA and inhaled corticosteroid (ICS). METHODS This was a retrospective, observational cohort study using health insurance claims data to identify COPD patients initiating LABA/LAMA or LABA/ICS. CCV outcomes included hospitalizations with a primary diagnosis for acute coronary syndrome, heart failure, cardiac dysrhythmia, stroke, or transient ischemic attack. Patients were followed until they experienced an event, discontinued treatment, initiated medication from the opposite cohort, or lost enrollment. Patients were matched 1:4 on propensity scores, and time to event was compared using Cox proportional hazards models. RESULTS After matching, there were 3842 patients in the LABA/LAMA cohort and 15 225 in the LABA/ICS cohort. Cardiovascular events in the LABA/LAMA cohort were lower than in the LABA/ICS: hazard ratio (HR) = 0.794; 95% CI = 0.623-0.997. No significant difference in the risk of cerebrovascular events (HR = 1.166; 95% CI = 0.653-1.959) was observed. CONCLUSIONS Despite concerns about the CCV effects of LAMA and LABA monotherapy, the LABA/LAMA combination had similar or lower risk of these events in comparison to LABA/ICS. Further studies are recommended to confirm these findings.
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Affiliation(s)
| | - Min J Joo
- 1 University of Illinois at Chicago, IL, USA
| | | | | | | | - Todd A Lee
- 1 University of Illinois at Chicago, IL, USA
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Chen WC, Huang CH, Sheu CC, Chong IW, Chu KA, Chen YC, Tsai JR, Lee CH, Wei YF. Long-acting beta2-agonists versus long-acting muscarinic antagonists in patients with stable COPD: A systematic review and meta-analysis of randomized controlled trials. Respirology 2017; 22:1313-1319. [DOI: 10.1111/resp.13100] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 03/28/2017] [Accepted: 04/26/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Wang-Chun Chen
- Department of Pharmacy; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
| | - Chi-Hsien Huang
- Department of Family Medicine; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
- Center for Evidence-Based Medicine and Center for Meta-Analysis Research; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Department of Internal Medicine, College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Research Center for Environmental Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Inn-Wen Chong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Research Center for Environmental Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Department of Respiratory Therapy and Graduate Institute of Medicine, College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Kuo-An Chu
- Division of Chest Medicine, Department of Internal Medicine; Kaohsiung-Veterans General Hospital; Kaohsiung Taiwan
| | - Yung-Che Chen
- Division of Pulmonary and Critical Care Medicine; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
| | - Jong-Rung Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Research Center for Environmental Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Department of Respiratory Therapy, College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Cheng-Hung Lee
- Division of Chest Medicine, Department of Internal Medicine; National Cheng Kung University Hospital; Tainan Taiwan
| | - Yu-Feng Wei
- Institute of Biotechnology and Chemical Engineering; I-Shou University; Kaohsiung Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine; E-Da Hospital, I-Shou University; Kaohsiung Taiwan
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Abstract
Evidence-based guidelines recommend inhaled long-acting anti-muscarinic agents (LAMAs) as first-line maintenance therapy for symptomatic patients with COPD. Several LAMAs are now available for use either as monotherapy or in combination with other COPD medications, including long-acting β2-agonists (LABAs) or inhaled corticosteroids (ICS). The efficacy and long-term safety of these medications have been evaluated in multiple clinical trials and real-life studies. This review evaluates the evidence available on the safety of existing LAMAs alone or in combination with LABAs and ICS in patients with COPD.
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Affiliation(s)
- Nicola A Hanania
- a Section of Pulmonary and Critical Care Medicine , Baylor College of Medicine , Houston , TX , USA
| | - Suzanne C Lareau
- b College of Nursing , University of Colorado Denver , Aurora , CO , USA
| | - Barbara P Yawn
- c Department of Family and Community Health , University of Minnesota , Minneapolis , MN , USA
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Halpin DM, Kaplan AG, Russell RK. Why choose tiotropium for my patient? A comprehensive review of actions and outcomes versus other bronchodilators. Respir Med 2017; 128:28-41. [PMID: 28610667 DOI: 10.1016/j.rmed.2017.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) and asthma are leading causes of morbidity and mortality. This narrative review provides an appraisal of the pharmacological and clinical characteristics of tiotropium in COPD and asthma, and examines how these compare with other long-acting bronchodilators. The evidence base is placed into context by relating it to factors affecting clinicians' choice of therapy. MAIN FINDINGS Desirable attributes of a long-acting muscarinic antagonist (LAMA) maintenance therapy include effective pharmacological bronchodilation, improved lung function, exacerbation efficacy, and positive effects on symptom control, exercise capacity and quality of life across a broad patient population. Tolerability and convenience of use are also important for patient well-being and treatment adherence. Tiotropium shows higher affinity for muscarinic receptors than ipratropium, and prolonged binding to the M3 receptor compared with other LAMAs. In COPD, tiotropium has demonstrated improved lung function and exacerbation prevention compared with placebo or long-acting β2-agonists, similar exacerbation efficacy to other LAMAs, and enhanced symptom control and health status versus placebo. UniTinA-asthma® showed the benefits of add-on tiotropium in patients with uncontrolled mild to moderate and severe asthma. Tiotropium is well tolerated, with an incidence of adverse events similar to placebo, except for known infrequent side effects of anticholinergics. Tiotropium HandiHaler® and Respimat® augment inhaler choice in COPD. PRINCIPAL CONCLUSIONS With over 10 years' prescribing history and 50 million patient-years of use, tiotropium has the benefit of a more extensive clinical evidence base than other long-acting bronchodilators, with demonstrated efficacy and safety in COPD and symptomatic asthma.
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Affiliation(s)
- David M Halpin
- Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, United Kingdom.
| | - Alan G Kaplan
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, ON M5G 1V7, Canada.
| | - Richard K Russell
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DS, United Kingdom.
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Pellicori P, Salekin D, Pan D, Clark AL. This patient is not breathing properly: is this COPD, heart failure, or neither? Expert Rev Cardiovasc Ther 2017; 15:389-396. [DOI: 10.1080/14779072.2017.1317592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Schivo M, Albertson TE, Haczku A, Kenyon NJ, Zeki AA, Kuhn BT, Louie S, Avdalovic MV. Paradigms in chronic obstructive pulmonary disease: phenotypes, immunobiology, and therapy with a focus on vascular disease. J Investig Med 2017; 65:953-963. [PMID: 28258130 DOI: 10.1136/jim-2016-000358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2017] [Indexed: 12/21/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous syndrome that represents a major global health burden. COPD phenotypes have recently emerged based on large cohort studies addressing the need to better characterize the syndrome. Though comprehensive phenotyping is still at an early stage, factors such as ethnicity and radiographic, serum, and exhaled breath biomarkers have shown promise. COPD is also an immunological disease where innate and adaptive immune responses to the environment and tobacco smoke are altered. The frequent overlap between COPD and other systemic diseases, such as cardiovascular disease, has influenced COPD therapy, and treatments for both conditions may lead to improved patient outcomes. Here, we discuss current paradigms that center on improving the definition of COPD, understanding the immunological overlap between COPD and vascular inflammation, and the treatment of COPD-with a focus on comorbid cardiovascular disease.
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Affiliation(s)
- Michael Schivo
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Center for Comparative Respiratory Biology and Medicine, Genome and Biomedical Sciences Facility, University of California Davis, Davis, California, USA
| | - Timothy E Albertson
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Department of Medicine, Veterans Administration Northern California Healthcare System, Mather, California, USA
| | - Angela Haczku
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Center for Comparative Respiratory Biology and Medicine, Genome and Biomedical Sciences Facility, University of California Davis, Davis, California, USA
| | - Nicholas J Kenyon
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Center for Comparative Respiratory Biology and Medicine, Genome and Biomedical Sciences Facility, University of California Davis, Davis, California, USA
| | - Amir A Zeki
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Center for Comparative Respiratory Biology and Medicine, Genome and Biomedical Sciences Facility, University of California Davis, Davis, California, USA
| | - Brooks T Kuhn
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Samuel Louie
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Center for Comparative Respiratory Biology and Medicine, Genome and Biomedical Sciences Facility, University of California Davis, Davis, California, USA
| | - Mark V Avdalovic
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Department of Medicine, Veterans Administration Northern California Healthcare System, Mather, California, USA
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Cazzola M, Calzetta L, Rogliani P, Matera MG. Tiotropium formulations and safety: a network meta-analysis. Ther Adv Drug Saf 2017; 8:17-30. [PMID: 28203364 PMCID: PMC5298465 DOI: 10.1177/2042098616667304] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Tiotropium is now delivered via two different inhaler devices: the original Handihaler 18 μg once daily, which uses a powder formulation; and the newer Respimat Soft Mist Inhaler (SMI) 5 μg once daily. It has been questioned whether the two devices can be assumed to have the same safety profile, although the TIOSPIR trial showed that tiotropium when administered via Respimat SMI 5 μg is not less safe than Handihaler 18 μg. Therefore, we have carried out a safety evaluation of tiotropium Handihaler 18 µg versus tiotropium Respimat SMI 5 µg and 2.5 µg, via systematic review and network meta-analysis of the currently available clinical evidence. The results of our meta-analysis with an extremely large number of patients analysed demonstrate that the safety profile of tiotropium HandiHaler is generally superior to that of tiotropium Respimat SMI, although no statistical difference was detected between these two devices. However, the SUCRA analysis favoured tiotropium Respimat SMI with regards to serious adverse events (AEs). We do not believe that using Respimat SMI rather that HandiHaler exposes patients to higher risks of real AEs. Rather, we believe that there may be a different cardiovascular (CV) response to muscarinic receptors blockage in individual patients. Therefore, it will be essential to make all possible efforts to proactively identify patients at increased risk of CV AEs when treated with tiotropium or another antimuscarinic drug.
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Affiliation(s)
- Mario Cazzola
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Luigino Calzetta
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paola Rogliani
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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Giorgini P, Di Giosia P, Ferri L, Ferri C. Cardiovascular events in patients with chronic obstructive bronchopulmonary disease. J Cardiovasc Med (Hagerstown) 2017; 18 Suppl 1:e23-e29. [DOI: 10.2459/jcm.0000000000000437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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40
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Efficacy of Continuous Positive Airway Pressure in the Treatment of Chronic Obstructive Pulmonary Disease Combined With Respiratory Failure. Am J Ther 2016; 23:e439-50. [PMID: 25768378 DOI: 10.1097/mjt.0000000000000222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Our aim is to investigate the efficacy of continuous positive airway pressure (CPAP) in chronic obstructive pulmonary disease (COPD) combined with respiratory failure. Electronic and manual searches were applied to retrieve published studies relevant to CPAP, COPD, and respiratory failure. The retrieved studies were screened based on stringent inclusion and exclusion criteria to identify high-quality clinical studies for meta-analysis. Comprehensive meta-analysis 2.0 was conducted to statistical analysis. Initially, we retrieved 958 studies based on stringent inclusion and exclusion criteria, 10 studies, containing a total of 372 patients with COPD combined with respiratory failure, were selected for meta-analysis. The result of our meta-analysis revealed that partial pressure of carbon dioxide (PaCO2) in patients with COPD combined with respiratory failure was significantly lower 24 hours after CPAP treatment, and partial pressure of oxygen (PaO2) and pH were markedly higher 24 hours after CPAP treatment in the same patient group, indicating statistically significant differences as a result of CPAP treatment. Subgroup analysis based on ethnicity demonstrated that PaCO2 in patients with COPD combined with respiratory failure is evidently lower 24 hours after CPAP treatment among whites, but no such statistical correlation was observed among Asians. The results of this meta-analysis indicate that CPAP can effectively improve the respiratory function of patients with COPD combined with respiratory failure, and CPAP can be an effective way of treating COPD.
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Albertson TE, Chenoweth JA, Adams JY, Sutter ME. Muscarinic antagonists in early stage clinical development for the treatment of asthma. Expert Opin Investig Drugs 2016; 26:35-49. [PMID: 27927039 DOI: 10.1080/13543784.2017.1264388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Parasympathetic neurons utilize the neurotransmitter acetylcholine to modulate and constrict airway smooth muscles at the muscarinic acetylcholine receptor. Inhaled agents that antagonize the muscarinic (M) acetylcholine receptor, particularly airway M3 receptors, have increasing data supporting use in persistent asthma. Areas covered: Use of inhaled long-acting muscarinic antagonists (LAMA) in asthma is explored. The LAMA tiotropium is approved for maintenance in symptomatic asthma patients despite the use of inhaled corticosteroids (ICS), leukotriene receptor antagonists (LTRA) and/or long-acting beta2 agonists (LABA). LAMA agents currently approved for chronic obstructive pulmonary disease (COPD) include tiotropium, glycopyrrolate/glycopyrronium, umeclidinium and aclidinium. These agents are reviewed for their pharmacological differences and clinical trials in asthma. Expert opinion: Current guidelines place inhaled LAMAs as adjunctive maintenance therapy in symptomatic asthma not controlled by an ICS and/or a LTRA. LAMA agents will play an increasing role in moderate to severe symptomatic asthma patients. Additional LAMA agents are likely to seek a maintenance indication perhaps as a combined inhaler with an ICS or with an ICS and a LABA. These fixed-dose combination inhalers are being tested in COPD and asthma patients. Once-a-day dosing of inhaled LAMA agents in severe asthma patients will likely become the future standard.
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Affiliation(s)
- Timothy E Albertson
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA.,b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - James A Chenoweth
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - Jason Y Adams
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA
| | - Mark E Sutter
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
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Anticholinergic Medication Burden and 5-Year Risk of Hospitalization and Death in Nursing Home Elderly Residents With Coronary Artery Disease. J Am Med Dir Assoc 2016; 17:1056-1059. [DOI: 10.1016/j.jamda.2016.07.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/21/2016] [Indexed: 01/07/2023]
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43
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Dahl R, Kaplan A. A systematic review of comparative studies of tiotropium Respimat® and tiotropium HandiHaler® in patients with chronic obstructive pulmonary disease: does inhaler choice matter? BMC Pulm Med 2016; 16:135. [PMID: 27724909 PMCID: PMC5057252 DOI: 10.1186/s12890-016-0291-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In many countries worldwide, the long-acting anticholinergic drug tiotropium is available as a dry powder formulation delivered by means of the HandiHaler® inhalation device and as an aqueous solution delivered via the Respimat® Soft Mist™ Inhaler. Tiotropium HandiHaler® is a single-dose, dry powder, breath-actuated inhaler that provides delivered doses and lung deposition of tiotropium that are, over a wide range, not influenced by the severity of chronic obstructive pulmonary disease (COPD). Tiotropium Respimat® is a propellant-free, multi-dose inhaler that delivers a metered dose of medication as a fine, slow-moving, long-lasting soft mist, independently of patient inspiratory effort. The high fine-particle fraction of droplets produced by the Respimat® inhaler optimizes the efficiency of drug delivery to the lungs. METHODS To help inform the choice of tiotropium inhaler for prescribers and patients, this systematic review summarizes the available pharmacokinetic, efficacy and safety data from comparative studies of tiotropium Respimat® and tiotropium HandiHaler® in COPD, focusing on the licensed once-daily doses of 5 and 18 μg, respectively. Data sources reviewed include publications and abstracts identified from database searches. RESULTS Published evidence from comparative studies suggests that tiotropium Respimat® 5 μg and tiotropium HandiHaler® 18 μg provide similar clinical outcomes in patients with COPD. CONCLUSIONS The findings indicate that physicians can base their decision about an inhaler for tiotropium on factors other than efficacy or safety. These could be patient preference for a particular inhaler, ease of use and the efficiency of drug delivery, with the aim of optimizing adherence and clinical outcomes with long-term tiotropium maintenance therapy.
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Affiliation(s)
- Ronald Dahl
- Odense University Hospital, Odense, Denmark.
| | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, ON, Canada
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Aljaafareh A, Valle JR, Lin YL, Kuo YF, Sharma G. Risk of cardiovascular events after initiation of long-acting bronchodilators in patients with chronic obstructive lung disease: A population-based study. SAGE Open Med 2016; 4:2050312116671337. [PMID: 27757229 PMCID: PMC5052927 DOI: 10.1177/2050312116671337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 08/02/2016] [Indexed: 11/29/2022] Open
Abstract
Objectives: Long-acting bronchodilators are mainstay treatment for moderate to severe chronic obstructive pulmonary disease. A growing body of evidence indicates an increased risk of cardiovascular events upon initiation of these medications. We hypothesize that this risk is higher in patients with chronic obstructive pulmonary disease who had a preexisting cardiovascular disease regardless of receipt of any cardiovascular medication. Methods: A retrospective cohort of patients with a diagnosis of chronic obstructive pulmonary disease based on two outpatient visits or one inpatient visit for chronic obstructive pulmonary disease (International Classification of Diseases, 9th Edition, Clinical Modification codes 491.x, 492.x, 496) in any year between 2001 and 2012 from a commercial insurance database. We then selected those initiating long-acting bronchodilator treatments between April 2001 and September 2012. Each patient had a 1 year look back period to determine history of cardiovascular disease or cardiovascular disease treatment from the time of first prescription of long-acting beta agonist, long-acting muscarinic antagonist, or long-acting beta agonist combined with inhaled corticosteroids. Patients were followed for 90 days for hospitalizations or emergency department visits for cardiovascular event. The cohort was divided into four groups based on the presence of cardiovascular disease (including ischemic heart disease, hypertension, ischemic stroke, heart failure, tachyarrhythmias and artery disease based on International Classification of Diseases, 9th Edition, Clinical Modification codes) and cardiovascular disease treatment defined as acetylsalicylic acid, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, antiplatelet, anticoagulants, calcium channel blockers, nitrate, digoxin, diuretics, antiarrhythmics or statins. Odds of emergency department visit or hospitalization in the 90 days after prescription were examined using multivariable logistic regression models. Results: Of 61,651 eligible patients, 36,755 (59.6%) had cardiovascular disease and were on cardiovascular disease treatment (Group 1), 7250 (11.8%) had cardiovascular disease without cardiovascular disease treatment (Group 2), 4715 (7.7%) had no cardiovascular disease but had cardiovascular disease treatment (Group 3) and 12,931 (21%) had no cardiovascular disease and no treatment (Group 4). In these four groups, the unadjusted risk of emergency department visit or hospitalization for cardiovascular disease within 90 days of initiation was 5.45%, 2.95%, 1.55% and 0.96%, respectively. In multivariable analysis, the adjusted odds ratio with 95% confidence interval of emergency department visit/hospitalization for each of the first three groups to those with no cardiovascular disease and no treatment were 3.50 (95% confidence interval, 2.89–4.24), 2.15 (95% confidence interval, 1.71–2.70) and 1.36 (95% confidence interval, 1.01–1.82), respectively. Conclusion: The risk of cardiovascular events after initiation of long-acting bronchodilators is highest in patients with baseline cardiovascular disease and on cardiovascular disease medications. Clinicians should be cautious while prescribing these medications in patients with preexisting cardiovascular disease.
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Affiliation(s)
- Almotasembellah Aljaafareh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jose Ruben Valle
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Yu-Li Lin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Yong-Fang Kuo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Gulshan Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Tan CK, Say GQ, Geake JB. Long-term safety of tiotropium delivered by Respimat ® SoftMist™ Inhaler: patient selection and special considerations. Ther Clin Risk Manag 2016; 12:1433-1444. [PMID: 27703365 PMCID: PMC5036544 DOI: 10.2147/tcrm.s109011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Tiotropium bromide is a long-acting inhaled muscarinic antagonist used in patients with chronic respiratory disease. It has been available since 2002 as a single-dose dry powder formulation via the HandiHaler® dry powder inhaler (DPI) device, and since 2007 as the Respimat® SoftMist™ Inhaler (SMI). The latter is a novel method of medication delivery that utilizes a multidose aqueous solution to deliver the drug as a fine mist. Potential benefits include more efficient drug deposition throughout the respiratory tract, reduced systemic exposure, and greater ease of use and patient satisfaction compared with the use of HandiHaler DPI. Although tiotropium bromide delivered via the HandiHaler DPI has been clearly shown to improve lung function, dyspnea, and quality of life and to reduce exacerbations in patients with chronic obstructive pulmonary disease (COPD), there is accumulating evidence regarding the use of tiotropium HandiHaler in other respiratory diseases characterized by airflow limitation, such as asthma and cystic fibrosis. Developed more recently, tiotropium delivered via the Respimat SMI appears to have a similar efficacy and safety profile to the HandiHaler DPI, and early data raising the possibility of safety concerns with its use in COPD have been refuted by more recent evidence. The benefits over the HandiHaler DPI, however, remain unclear. This paper will review the evidence for tiotropium delivered via the Respimat SMI inhaler, in particular as an alternative to the HandiHaler DPI, and will focus on the safety profile for each of the chronic lung diseases in which it has been trialed, as well as an approach to appropriate patient selection.
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Affiliation(s)
- Ching Kuo Tan
- Department of Respiratory Medicine, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| | - Gui Quan Say
- Department of Respiratory Medicine, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| | - James B Geake
- Department of Respiratory Medicine, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
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Montuschi P, Malerba M, Macis G, Mores N, Santini G. Triple inhaled therapy for chronic obstructive pulmonary disease. Drug Discov Today 2016; 21:1820-1827. [PMID: 27452453 DOI: 10.1016/j.drudis.2016.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/15/2016] [Accepted: 07/14/2016] [Indexed: 02/05/2023]
Abstract
Combining individual drugs in a single inhaler is the most convenient way to deliver triple therapy. A long-acting muscarinic receptor antagonist (LAMA) added to an inhaled corticosteroid (ICS)/long-acting β2-adrenoceptor agonist (LABA) fixed-dose combination (FDC) can improve efficacy of pharmacological treatment of patients with chronic obstructive pulmonary disease (COPD). New inhaled ICS/LABA/LAMA FDCs, including fluticasone furoate/vilanterol/umeclidinium, budesonide/formoterol/glycopyrronium and beclometasone/formoterol/glycopyrronium, are in Phase III of clinical development for COPD. Triple inhaled therapy might be particularly useful in patients with severe to very severe COPD, above all in those with peripheral blood or sputum eosinophilia, asthma-COPD overlap syndrome (ACOS) or frequent exacerbators. Future prospective studies should assess efficacy and safety of triple ICS/LABA/LAMA therapy in selected COPD phenotypes.
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Affiliation(s)
- Paolo Montuschi
- Department of Pharmacology, Faculty of Medicine, University Hospital Agostino Gemelli, Catholic University of the Sacred Heart, Rome, Italy.
| | - Mario Malerba
- Department of Internal Medicine, University of Brescia, Brescia, Italy
| | - Giuseppe Macis
- Department of Radiological Sciences, Faculty of Medicine, University Hospital Agostino Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Nadia Mores
- Department of Pharmacology, Faculty of Medicine, University Hospital Agostino Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Santini
- Department of Pharmacology, Faculty of Medicine, University Hospital Agostino Gemelli, Catholic University of the Sacred Heart, Rome, Italy
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Lee CH, Choi S, Jang EJ, Kim DW, Yoon HI, Kim YJ, Kim J, Yim JJ, Kim DK. The effects of inhaled respiratory drugs on the risk of stroke: A nested case-control study. Pulm Pharmacol Ther 2016; 40:7-14. [PMID: 27418383 DOI: 10.1016/j.pupt.2016.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/07/2016] [Accepted: 07/09/2016] [Indexed: 11/19/2022]
Abstract
Although there have been concerns that inhaled long-acting muscarinic antagonists increase the risk of stroke, controversies exist. We investigated whether respiratory drugs including long-acting muscarinic antagonists are associated with the risk of stroke. A nested case-control study using the nationwide insurance claims database of the Health Insurance Review and Assessment Service (Seoul, Republic of Korea) was conducted. Overall, 16,354 stroke cases and 74,451 matched (up to 1:5) controls were identified from 809,684 subjects without acute major cardiovascular events in the past year between January 1, 2010, and December 31, 2011. To determine whether the use of inhaled respiratory drugs is associated with the risk of stroke, conditional logistic regression analysis adjusted by comorbidities, cardiovascular drugs and healthcare utilization was performed. After adjusting for covariates, there were no statistically significant effects of the inhaled drugs on stroke incidence, except for inhaled corticosteroids without a long-acting β2-agonists, which was significantly associated with hemorrhagic stroke. Inhaled respiratory medications, including long-acting muscarinic antagonists, did not affect the risk of stroke in the inhaled respiratory drug users.
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Affiliation(s)
- Chang-Hoon Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seongmi Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Department of Statistics, Kyungpook National University College of Natural Sciences, Daegu, Republic of Korea
| | - Eun Jin Jang
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Department of Information Statistics, Colloge of Natural Science, Andong National University, Andong, Republic of Korea
| | - Dong-Wook Kim
- Department of Neurology, College of Medicine, Konkuk University, Seoul, Republic of Korea
| | - Ho Il Yoon
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Republic of Korea
| | - Yun Jung Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Jimin Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Jae-Joon Yim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Deog Kyeom Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea.
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Fadda V, Maratea D. Long-term outcomes in chronic obstructive pulmonary disease patients: exploring the effects of inhalatory devices and their influence on the outcome. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:87-95. [PMID: 27186072 PMCID: PMC4847594 DOI: 10.2147/ceor.s75132] [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] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Numerous systematic reviews have examined the outcomes in patients with chronic obstructive pulmonary disease managed with different therapeutic strategies. However, no such studies have specifically focused on the effect of inhalation devices. METHODS A standard PubMed search was carried out in which we identified all randomized placebo-controlled trials conducted in patients with moderate-to-severe or severe chronic obstructive pulmonary disease. The clinical end points were exacerbations rate, incidence of pneumonia, and mortality. Meta-regression was employed to assess the effect of the device. For the incidence of exacerbations, an equivalence analysis was also carried out. RESULTS A total of 37 studies were analyzed. Four different devices were used across these trials (Respimat(®), HandiHaler(®), Diskus, and Turbuhaler(®)). Our meta-regression analysis failed to show any significant difference between devices with regard to exacerbation rate. Equivalence was shown for some comparisons (HandiHaler(®) vs Respimat(®)), but not for others. In analyzing mortality, Respimat(®) was shown to worsen this end point in comparison with Turbuhaler(®) and HandiHaler(®). Moreover, Turbuhaler(®) showed a protective effect over Diskus in the incidence of pneumonia. CONCLUSION The results of our analysis represent the first attempt to explore the effect of the type of device on long-term outcomes. One important limitation was that most drugs were associated with one particular device, and so the effects of drugs and devices could not be reliably differentiated from one another.
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Affiliation(s)
- Valeria Fadda
- Department of Pharmaceutical Sciences, University of Florence, Sesto Fiorentino, FI, Italy
| | - Dario Maratea
- Department of Pharmaceutical Sciences, University of Florence, Sesto Fiorentino, FI, Italy
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Carvalho TC, McConville JT. The function and performance of aqueous aerosol devices for inhalation therapy. ACTA ACUST UNITED AC 2016; 68:556-78. [PMID: 27061412 DOI: 10.1111/jphp.12541] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 02/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In this review paper, we explore the interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations for several types of devices, namely jet, ultrasonic and vibrating-mesh nebulizers; colliding and extruded jets; electrohydrodynamic mechanism; surface acoustic wave microfluidic atomization; and capillary aerosol generation. KEY FINDINGS Nebulization is the transformation of bulk liquids into droplets. For inhalation therapy, nebulizers are widely used to aerosolize aqueous systems, such as solutions and suspensions. The interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations plays a significant role in the performance of aerosol generation appropriate for pulmonary delivery. Certain types of nebulizers have consistently presented temperature increase during the nebulization event. Therefore, careful consideration should be given when evaluating thermo-labile drugs, such as protein therapeutics. We also present the general approaches for characterization of nebulizer formulations. SUMMARY In conclusion, the interplay between the dosage form (i.e. aqueous systems) and the specific type of device for aerosol generation determines the effectiveness of drug delivery in nebulization therapies, thus requiring extensive understanding and characterization.
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Affiliation(s)
- Thiago C Carvalho
- Bristol-Myers Squibb, Drug Product Science & Technology, New Brunswick, NJ, USA
| | - Jason T McConville
- Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, USA
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Bellinger CR, Peters SP. Outpatient Chronic Obstructive Pulmonary Disease Management: Going for the GOLD. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 3:471-8; quiz 479-80. [PMID: 26164571 DOI: 10.1016/j.jaip.2015.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/21/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States with a burden of $50 billion in direct health care costs. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines airflow obstruction as spirometry where the ratio of forced expiratory volume in the first second to forced vital capacity after bronchodilation is less than 0.70. The guidelines also provided graded recommendations on current therapy for COPD. Treatment can be guided based on severity of disease and severity of symptoms. We review the GOLD guidelines to provide an overview of treatment modalities aimed at improving lung function, reducing hospitalization, and reducing mortality.
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Affiliation(s)
- Christina R Bellinger
- Wake Forest School of Medicine, Section on Pulmonary, Critical Care, Allergy & Immunologic Diseases, Winston-Salem, NC.
| | - Stephen P Peters
- Wake Forest School of Medicine, Section on Pulmonary, Critical Care, Allergy & Immunologic Diseases, Winston-Salem, NC
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