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Sciurba FC, Christenson SA, Rheault T, Bengtsson T, Rickard K, Barjaktarevic IZ. Dual Phosphodiesterase 3 and 4 Inhibitor Ensifentrine Reduces Exacerbation Rate and Risk in Patients With Moderate to Severe COPD. Chest 2024:S0012-3692(24)04937-7. [PMID: 39197510 DOI: 10.1016/j.chest.2024.07.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/11/2024] [Accepted: 07/23/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Exacerbations in COPD can be life-threatening and can lead to irreversible declines in lung function and quality of life. Medications that reduce exacerbation burden are an unmet need, because exacerbations put patients at risk of more exacerbations and decrease quality of life. Ensifentrine is a novel, first-in-class, selective, dual inhibitor of phosphodiesterase 3 and 4 with demonstrated nonsteroidal antiinflammatory activity and bronchodilatory effects. RESEARCH QUESTION Does ensifentrine reduce the rate or risk of COPD exacerbations? STUDY DESIGN AND METHODS A prespecified, pooled analysis of the phase 3 clinical trials ENHANCE-1 (ClinicalTrials.gov Identifier: NCT04535986) and ENHANCE-2 (ClinicalTrials.gov Identifier: NCT04542057) was conducted to assess the effect of ensifentrine on exacerbation rate and risk (time to first exacerbation). The trials included symptomatic patients 40 to 80 years of age with moderate to severe COPD who received 3 mg tid ensifentrine over 24 weeks or placebo. Subgroup analyses and frequent exacerbator transition risk assessment were conducted post hoc. RESULTS In total, 975 patients treated with ensifentrine and 574 patients who received placebo were included in the pooled analysis, including 62% of patients receiving concomitant long-acting muscarinic antagonist or long-acting β2-agonist therapy and 18% receiving concomitant inhaled corticosteroid therapy. Ensifentrine was associated with significant reductions in the rate (rate ratio, 0.59; 95% CI, 0.43-0.80; P < .001) and risk (hazard ratio, 0.59; 95% CI, 0.44-0.81; P < .001) of moderate to severe exacerbations compared with placebo. Reductions in the rate and risk of exacerbations generally were consistent across patient subgroups, including age, sex, race, background maintenance medication use, chronic bronchitis, eosinophil count, COPD severity, and exacerbation history. Ensifentrine was associated with a numerical delay in transitioning from an infrequent exacerbator (Global Initiative for Chronic Obstructive Lung Disease [GOLD] group B) to a frequent exacerbator (GOLD group E) compared with placebo. INTERPRETATION Ensifentrine reduced the rate of exacerbations and increased the time to first exacerbation among patients with COPD across a broad range of clinically relevant subgroups.
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Affiliation(s)
- Frank C Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephanie A Christenson
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco
| | | | | | | | - Igor Z Barjaktarevic
- Division of Pulmonary and Critical Care, University of California, Los Angeles, Los Angeles, CA.
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Li J, Zuo Y, Feng L, Cai YS, Su J, Tong Z, Liang L. Association of blood eosinophils with corticosteroid treatment failure stratified by smoking status among inpatients with AECOPD. BMJ Open Respir Res 2024; 11:e001634. [PMID: 38609180 PMCID: PMC11029211 DOI: 10.1136/bmjresp-2023-001634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Recent studies have suggested elevated blood eosinophils are independent predictors of response to corticosteroid therapy in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Smoking status has been shown to affect corticosteroid response. Whether the association between high blood eosinophils and corticosteroid treatment failure is modified by smoking has not been fully investigated so far. OBJECTIVES This study aimed to assess whether the association between high blood eosinophils and corticosteroid treatment failure is modified by smoking. METHODS We included 3402 inpatients with AECOPD treated with corticosteroids at Beijing Chao-Yang Hospital from July 2013 to June 2021. Blood eosinophil counts were measured within 24 hours of admission. An eosinophil percentage ≥2% was considered as high eosinophilic. Smokers in this study were defined as current or former smokers. Treatment failure was defined as a worsening of AECOPD that led to adverse clinical outcomes or required further treatment or an extended hospital stay or hospitalisation following the exacerbation. Multivariate-adjusted logistic models were used to estimate the OR and 95% CI associated with treatment failure. RESULTS There were 958 (28.2%) treatment failure events occurring. Patients with high eosinophils had a lower risk of treatment failure (OR 0.74, 95% CI 0.63 to 0.87) than patients with low eosinophils. Compared with never smoking and low eosinophilic group, the ORs for treatment failure were 0.70 (95% CI 0.52 to 0.96) for never smoking and high eosinophilic group, 0.82 (95% CI 0.64 to 1.05) for smoking and low eosinophilic group and 0.62 (95% CI 0.47 to 0.81) for smoking and high eosinophilic group. Furthermore, there was no significant interaction between eosinophils and smoking status in relation to treatment failure (p for interaction=0.73). Similar results were obtained from multiple secondary outcomes and subgroup analyses. CONCLUSION Elevated blood eosinophils are associated with a lower rate of corticosteroid treatment failure, regardless of smoking status. Smoking does not modify the association between blood eosinophil level and corticosteroid treatment failure among inpatients with AECOPD.
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Affiliation(s)
- Jiachen Li
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yingting Zuo
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Lin Feng
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yutong Samuel Cai
- Centre for Environmental Health and Sustainability, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Jian Su
- School of Economics, Peking University, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao Yang Hospital, Capital Medical University, Beijing, China
| | - Lirong Liang
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Wu JJ, Zhang PA, Chen MZ, Zhang Y, Du WS, Li XN, Ji GC, Jiang LD, Jiao Y, Li X. Analysis of Key Genes and miRNA-mRNA Networks Associated with Glucocorticoids Treatment in Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2024; 19:589-605. [PMID: 38435123 PMCID: PMC10909375 DOI: 10.2147/copd.s441716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
Background Some patients with chronic obstructive pulmonary disease (COPD) benefit from glucocorticoid (GC) treatment, but its mechanism is unclear. Objective With the help of the Gene Expression Omnibus (GEO) database, the key genes and miRNA-mRNA related to the treatment of COPD by GCs were discussed, and the potential mechanism was explained. Methods The miRNA microarray dataset (GSE76774) and mRNA microarray dataset (GSE36221) were downloaded, and differential expression analysis were performed. Gene Ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed on the differentially expressed genes (DEGs). The protein interaction network of the DEGs in the regulatory network was constructed with the STRING database, and the key genes were screened through Cytoscape. Potential downstream target genes regulated by differentially expressed miRNAs (DEMs) were predicted by the miRWalk3.0 database, and miRNA-mRNA regulatory networks were constructed. Finally, some research results were validated. Results ① Four DEMs and 83 DEGs were screened; ② GO and KEGG enrichment analysis mainly focused on the PI3K/Akt signalling pathway, ECM receptor interaction, etc.; ③ CD2, SLAMF7, etc. may be the key targets of GC in the treatment of COPD; ④ 18 intersection genes were predicted by the mirwalk 3.0 database, and 9 pairs of miRNA-mRNA regulatory networks were identified; ⑤ The expression of miR-320d-2 and TFCP2L1 were upregulated by dexamethasone in the COPD cell model, while the expression of miR-181a-2-3p and SLAMF7 were downregulated. Conclusion In COPD, GC may mediate the expression of the PI3K/Akt signalling pathway through miR-181a-2-3p, miR-320d-2, miR-650, and miR-155-5p, targeting its downstream signal factors. The research results provide new ideas for RNA therapy strategies of COPD, and also lay a foundation for further research.
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Affiliation(s)
- Jian-Jun Wu
- Respiratory Department, The Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Ping-An Zhang
- Respiratory Department, The Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Ming-Zhe Chen
- Infectious Disease Department, Henan Provincial Hospital of Traditional Chinese Medicine, Zhengzhou, Henan, People’s Republic of China
| | - Yi Zhang
- Respiratory Department, The Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Wei-Sha Du
- Respiratory Department, The Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Xiao-Ning Li
- Respiratory Department, The Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Guo-Chao Ji
- Respiratory Department, The Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Liang-Duo Jiang
- Respiratory Department, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Yang Jiao
- Respiratory Department, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Xin Li
- Glaucoma Department, Eye Hospital, China Academy of Chinese Medical Sciences, Beijing, People’s Republic of China
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Beech A, Booth S, Higham A, Singh D. Current smoking reduces small airway eosinophil counts in COPD. ERJ Open Res 2024; 10:00870-2023. [PMID: 38259811 PMCID: PMC10801758 DOI: 10.1183/23120541.00870-2023] [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: 11/07/2023] [Accepted: 11/16/2023] [Indexed: 01/24/2024] Open
Abstract
Current smoking reduces small airway intraepithelial eosinophil counts in COPD patients and controls. This provides evidence of an attenuation of type-2 related inflammation in the small airways imposed by current smoking, which may affect ICS response. https://bit.ly/49YSKwG.
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Affiliation(s)
- Augusta Beech
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
- Medicines Evaluation Unit, Manchester, UK
| | - Sophie Booth
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
- Medicines Evaluation Unit, Manchester, UK
| | - Andrew Higham
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
- These authors contributed equally
| | - Dave Singh
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
- Medicines Evaluation Unit, Manchester, UK
- These authors contributed equally
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Alter P, Kahnert K, Trudzinski FC, Bals R, Watz H, Speicher T, Söhler S, Welte T, Rabe KF, Wouters EFM, Vogelmeier CF, Jörres RA. Clinical factors linked to the type of respiratory medication in COPD: results from the COSYCONET cohort. Ther Adv Respir Dis 2023; 17:17534666231208584. [PMID: 37936408 PMCID: PMC10631320 DOI: 10.1177/17534666231208584] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND The use of maintenance medication in patients with chronic obstructive pulmonary disease (COPD) in real life is known to deviate from recommendations in guidelines, which are largely based on randomized controlled trials and selected populations. OBJECTIVES We used the COSYCONET (COPD and Systemic Consequences - Comorbidities Network) cohort to analyze factors linked to the use of COPD drugs under non-interventional circumstances. DESIGN COSYCONET is an ongoing, multi-center, non-interventional cohort of patients with COPD. METHODS Patients with COPD of Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 0-4 participating in visits 1-5 were included. Data covered the period from 2010 to 2018. Generalized linear models were used to examine the relation of COPD characteristics to different types of respiratory medication. RESULTS A total of 1043 patients were included. The duration of observation was 4.5 years. Use of respiratory medication depended on GOLD grades 0-4 and groups A-D. Long-acting muscarinic antagonist therapy increased over time, and was associated with low carbon monoxide (CO) diffusing capacity, while inhaled corticosteroid (ICS) use decreased. Active smoking was associated with less maintenance therapy in general, and female sex with less ICS use. From the eight items of the COPD Assessment Test, only hill and stair climbing were consistently linked to treatment. CONCLUSION Using data from a large, close to real-life observational cohort, we identified factors linked to the use of various types of respiratory COPD medication. Overall, use was consistent with GOLD recommendations. Beyond this, we identified other correlates of medication use that may help us to understand and improve therapy decisions in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT01245933.
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Affiliation(s)
- Peter Alter
- Department of Medicine, Pulmonary, Critical Care and Sleep Medicine, Philipps University of Marburg (UMR), Baldingerstrasse 1, Marburg 35033, Germany
- German Center for Lung Research (DZL), Marburg, Germany
| | - Kathrin Kahnert
- Department of Medicine V, LMU University Hospital, LMU Munich, Comprehensive Pneumology Center, German Center for Lung Research (DZL), Munich, Germany
- MediCenterGermering, Germering, Germany
| | - Franziska C. Trudzinski
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Center for Lung Research (DZL), Heidelberg, Germany
| | - Robert Bals
- Department of Internal Medicine V – Pulmonology, Allergology, Intensive Care Medicine, Saarland University Hospital, Germany
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Tim Speicher
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Marburg, Germany
- German Center for Lung Research (DZL), Marburg, Germany
| | - Sandra Söhler
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Marburg, Germany
- German Center for Lung Research (DZL), Marburg, Germany
| | - Tobias Welte
- Clinic for Pneumology, Hannover Medical School, German Center for Lung Research (DZL), Hannover, Germany
| | - Klaus F. Rabe
- LungenClinic Grosshansdorf and Department of Medicine, Christian-Albrechts University, Kiel, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Emiel F. M. Wouters
- Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, Netherlands and Ludwig Boltzmann Institute for Lung Health, Vienna, Austria
| | - Claus F. Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Marburg, Germany
- German Center for Lung Research (DZL), Marburg, Germany
| | - Rudolf A. Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
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Miravitlles M, Matsunaga K, Dreher M. Stepwise management of COPD: What is next after bronchodilation? Ther Adv Respir Dis 2023; 17:17534666231208630. [PMID: 37936381 PMCID: PMC10631322 DOI: 10.1177/17534666231208630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, University Hospital Vall d′Hebron/Vall d’Hebron Research Institute (VHIR, Vall d’Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias [CIBERES]), P. Vall d’Hebron 119–129, Barcelona 08035, Spain
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
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Bardsley S, Criner GJ, Halpin DMG, Han MK, Hanania NA, Hill D, Lange P, Lipson DA, Martinez FJ, Midwinter D, Siler TM, Singh D, Wise RA, van Zyl-Smit RN, Berkman N. Single-inhaler triple therapy fluticasone furoate/umeclidinium/vilanterol versus dual therapy in current and former smokers with COPD: IMPACT trial post hoc analysis. Respir Med 2022; 205:107040. [PMID: 36470149 DOI: 10.1016/j.rmed.2022.107040] [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: 06/26/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Smoking is the major risk factor for chronic obstructive pulmonary disease (COPD). In IMPACT, single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) triple therapy significantly reduced moderate/severe exacerbation rates and improved lung function and health status versus FF/VI or UMEC/VI in COPD patients. This post hoc analysis investigated trial outcomes by smoking status. METHODS IMPACT was a double-blind, 52-week trial. Patients aged ≥40 years with symptomatic COPD and ≥1 moderate/severe exacerbation in the prior year were randomized 2:2:1 to FF/UMEC/VI 100/62.5/25 μg, FF/VI 100/25 μg, or UMEC/VI 62.5/25 μg. Endpoints assessed by smoking status at screening included rate and risk of moderate/severe exacerbations, change from baseline in trough forced expiratory volume in 1 s, and St George's Respiratory Questionnaire total score at Week 52. Safety was also assessed. RESULTS Of the 10,355 patients in the intent-to-treat population, 3,587 (35%) were current smokers. FF/UMEC/VI significantly reduced on-treatment moderate/severe exacerbation rates versus FF/VI and UMEC/VI in current (rate ratio 0.85 [95% confidence interval: 0.77-0.95]; P = 0.003 and 0.86 [0.76-0.98]; P = 0.021) and former smokers (0.85 [0.78-0.91]; P < 0.001 and 0.70 [0.64-0.77]; P < 0.001). FF/UMEC/VI significantly reduced time-to-first on-treatment moderate/severe exacerbation versus FF/VI and UMEC/VI in former smokers, and versus FF/VI in current smokers. Similar trends were seen for lung function and health status. Former smokers receiving inhaled corticosteroid-containing therapy had higher pneumonia incidence than current smokers. CONCLUSIONS FF/UMEC/VI improved clinical outcomes versus dual therapy regardless of smoking status. Benefits of FF/UMEC/VI versus UMEC/VI were greatest in former smokers, potentially due to relative corticosteroid resistance in current smokers. CLINICAL TRIAL REGISTRATION GSK (CTT116855/NCT02164513).
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Affiliation(s)
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - MeiLan K Han
- University of Michigan, Pulmonary & Critical Care, Ann Arbor, MI, USA
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - David Hill
- Waterbury Pulmonary Associates, Waterbury, CT, USA
| | - Peter Lange
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Medical Department, Pulmonary Section, Herlev-Gentofte Hospital, Herlev, Denmark
| | - David A Lipson
- GSK, Collegeville, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando J Martinez
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | | | | | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Foundation Hospital Trust, Manchester, UK
| | - Robert A Wise
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard N van Zyl-Smit
- Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Neville Berkman
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Neşe A, Samancıoğlu Bağlama S. The Effect of Progressive Muscle Relaxation and Deep Breathing Exercises on Dyspnea and Fatigue Symptoms of COPD Patients: A Randomized Controlled Study. Holist Nurs Pract 2022; 36:E18-E26. [PMID: 35708562 DOI: 10.1097/hnp.0000000000000531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was conducted to examine the effect of progressive muscle relaxation and deep breathing exercises applied to patients diagnosed with chronic obstructive pulmonary disease (COPD) on their dyspnea and fatigue symptoms. The study was a randomized controlled experimental trial and comprised 116 COPD patients who applied to a chest diseases follow-up outpatient clinic hospital located in Gaziantep, Turkey. The data were collected using the "Patient Information Form" including sociodemographic and disease-related characteristics of the patients, COPD and Asthma Fatigue Scale (CAFS), and Dyspnea-12 Scale. Dyspnea-12 Scale and CAFS total scores of the patients in the intervention group showed a statistically significant difference before and after the Progressive Relaxation Exercise and Deep Breathing Exercise applications (P < .05). Although the Dyspnea-12 Scale and CAFS total mean scores showed an increase in the intervention group, they remained the same in the control group. In the present study, it was found that the Progressive Muscle Relaxation Exercise and Deep Breathing Exercise applied to COPD patients were effective in decreasing their dyspnea and fatigue symptoms.
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Affiliation(s)
- Adile Neşe
- Gaziantep University Vocational School of Health Services, Gaziantep, Turkey (Dr Neşe); and Faculty of Health Sciences, Nursing Department, Muğla Sıtkı Kocaman University, Muğla, Turkey (Dr Samancıoğlu Bağlama)
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Maltais F, Vogelmeier CF, Kerwin EM, Bjermer LH, Jones PW, Boucot IH, Lipson DA, Tombs L, Compton C, Naya IP. Applying key learnings from the EMAX trial to clinical practice and future trial design in COPD. Respir Med 2022; 200:106918. [DOI: 10.1016/j.rmed.2022.106918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 10/18/2022]
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10
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Best Practice Management of Patients With Chronic Obstructive Pulmonary Disease: A Case-Based Review. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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NUCERA F, BIANCO A, DAVID T, SALVATO I, ADCOCK IM, CARAMORI G. Treatable traits in COPD patients. Minerva Med 2022; 113:449-459. [DOI: 10.23736/s0026-4806.22.08001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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12
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Cheng SL, Lin CH, Chu KA, Chiu KL, Lin SH, Lin HC, Ko HK, Chen YC, Chen CH, Sheu CC, Huang WC, Yang TM, Wei YF, Chien JY, Wang HC, Lin MC. Update on guidelines for the treatment of COPD in Taiwan using evidence and GRADE system-based recommendations. J Formos Med Assoc 2021; 120:1821-1844. [PMID: 34210585 DOI: 10.1016/j.jfma.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/14/2021] [Accepted: 06/11/2021] [Indexed: 12/20/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) has significant contributions to morbidity and mortality world-wide. Early symptoms of COPD are not readily distinguishable, resulting in a low rate of diagnosis and intervention. Different guidelines and recommendatations for the diagnosis and treatment of COPD exist globally. The first edition of clinical practice guidelines for COPD was published in 2016 by the Ministry of Health and Welfare in Taiwan in collaboration with the Taiwan evidence-based medicine association and Cochrane Taiwan, and was revised in 2019 in order to update recent diagnostic and therapeutic modalities for COPD and its acute exacerbation. This revised guideline covered a range of topics highlighted in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, including strategies for the diagnosis, assessment, monitoring, and management of stable COPD and exacerbations, with particular focus on evidence from Taiwan. The recommendations included in the revised guideline were formed based on a comprehensive systematic review or meta-analysis of specific clinical issues identified by an expert panel that surveyed relevant scientific evidence in the literature and guidelines published by the clinical communities and organizations nationally and internationally. The guidelines and recommendations are applicable to the clinical settings in Taiwan. We expect this revised guideline to facilitate the diagnosis, treatment and management of patients with COPD by physicians and health care professionals in Taiwan. Adaptations of the materials included herein for educational and training purposes is encouraged.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan; Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli City, Taoyuan County, Taiwan
| | - Ching-Hsiung Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Kuo-An Chu
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuo-Liang Chiu
- Division of Chest Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; School of Post-baccalaureate Chinese Medicine, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Sheng-Hao Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Horng-Chyuan Lin
- Lin-Kou Medical Center of Chang Gung Memorial Hospital, Kwei-San, Tao-Yan, Taiwan
| | - Hsin-Kuo Ko
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Che Chen
- Kaohsiung Chang Gung MemoriaI Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Hung Chen
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chang Huang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsung-Ming Yang
- Division of Pulmonary and Critical Care Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yu-Feng Wei
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan; Division of Chest Medicine, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Meng-Chih Lin
- Kaohsiung Chang Gung MemoriaI Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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13
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Bjermer LH, Boucot IH, Vogelmeier CF, Maltais F, Jones PW, Tombs L, Compton C, Lipson DA, Kerwin EM. Efficacy and Safety of Umeclidinium/Vilanterol in Current and Former Smokers with COPD: A Prespecified Analysis of The EMAX Trial. Adv Ther 2021; 38:4815-4835. [PMID: 34347255 PMCID: PMC8408076 DOI: 10.1007/s12325-021-01855-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/06/2021] [Indexed: 12/25/2022]
Abstract
Introduction Smoking may reduce the efficacy of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD), but its impact on bronchodilator efficacy is unclear. This analysis of the EMAX trial explored efficacy and safety of dual- versus mono-bronchodilator therapy in current or former smokers with COPD. Methods The 24-week EMAX trial evaluated lung function, symptoms, health status, exacerbations, clinically important deterioration, and safety with umeclidinium/vilanterol, umeclidinium, and salmeterol in symptomatic patients at low exacerbation risk who were not receiving ICS. Current and former smoker subgroups were defined by smoking status at screening. Results The analysis included 1203 (50%) current smokers and 1221 (50%) former smokers. Both subgroups demonstrated greater improvements from baseline in trough FEV1 at week 24 (primary endpoint) with umeclidinium/vilanterol versus umeclidinium (least squares [LS] mean difference, mL [95% CI]; current: 84 [50, 117]; former: 49 [18, 80]) and salmeterol (current: 165 [132, 198]; former: 117 [86, 148]) and larger reductions in rescue medication inhalations/day over 24 weeks versus umeclidinium (LS mean difference [95% CI]; current: − 0.42 [− 0.63, − 0.20]; former: − 0.25 − 0.44, − 0.05]) and salmeterol (current: − 0.28 [− 0.49, − 0.06]; former: − 0.29 [− 0.49, − 0.09]). Umeclidinium/vilanterol increased the odds (odds ratio [95% CI]) of clinically significant improvement at week 24 in Transition Dyspnea Index versus umeclidinium (current: 1.54 [1.16, 2.06]; former: 1.32 [0.99, 1.75]) and salmeterol (current: 1.37 (1.03, 1.82]; former: 1.60 [1.20, 2.13]) and Evaluating Respiratory Symptoms–COPD versus umeclidinium (current: 1.54 [1.13, 2.09]; former: 1.50 [1.11, 2.04]) and salmeterol (current: 1.53 [1.13, 2.08]; former: 1.53 [1.12, 2.08]). All treatments were well tolerated in both subgroups. Conclusions In current and former smokers, umeclidinium/vilanterol provided greater improvements in lung function and symptoms versus umeclidinium and salmeterol, supporting consideration of dual-bronchodilator therapy in symptomatic patients with COPD regardless of their smoking status. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01855-y. Patients with chronic obstructive pulmonary disease (COPD) often require daily medication to control their COPD. Many patients with COPD are smokers, and smoking is one of the most common causes of COPD. This means that it is important to find out whether COPD medications are effective in both smokers and nonsmokers. We analyzed data from a clinical trial (EMAX) that investigated the use of a combination of two bronchodilators, which are inhaled medications that help to open the airways. We compared umeclidinium/vilanterol, a dual-bronchodilator combination, with a single bronchodilator (either umeclidinium or salmeterol) over 6 months. We found that both current and former smokers who were treated with umeclidinium/vilanterol had larger improvements in lung function than those receiving umeclidinium or salmeterol. Current or former smokers who were treated with umeclidinium/vilanterol used their reliever inhaler less than those treated with umeclidinium or salmeterol. Patients treated with umeclidinium/vilanterol were generally less likely to experience disease worsening compared with umeclidinium or salmeterol if they were former smokers, or compared with salmeterol if they were current smokers. Our findings suggest that umeclidinium/vilanterol may be more effective than a single bronchodilator for daily treatment of patients with COPD who are current or former smokers. Physicians should consider prescribing a combination of two bronchodilators to patients who have symptoms, whether or not they currently smoke, as well as encouraging smoking cessation for all patients.
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14
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Calverley PMA, Walker PP. ACO (Asthma-COPD Overlap) Is Independent from COPD: The Case in Favour. Diagnostics (Basel) 2021; 11:1189. [PMID: 34208874 PMCID: PMC8304638 DOI: 10.3390/diagnostics11071189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/16/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022] Open
Abstract
Over the last decade interest has been shown in people with symptomatic lung disease who have features both of COPD and asthma. In this review we examine how COPD and asthma are defined and examine clinical characteristics of people defined by researchers as having asthma-COPD overlap (ACO). We look at pathological and physiological features along with symptoms and consider the impact of each diagnosis upon therapeutic management. We highlight challenges in the diagnosis and management of airway disease and the various phenotypes that could be part of ACO, in so doing suggesting ways for the clinician to manage patients with features of both asthma and COPD.
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Affiliation(s)
| | - Paul Phillip Walker
- Liverpool University Hospitals Foundation NHS, University of Liverpool, Liverpool L9 7AL, UK
- Department of Respiratory Medicine, Aintree Hospital, Lower Lane, Liverpool L9 7AL, UK
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15
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Corticosteroid Resistance in Smokers-A Substudy Analysis of the CORTICO-COP Randomised Controlled Trial. J Clin Med 2021; 10:jcm10122734. [PMID: 34205765 PMCID: PMC8234000 DOI: 10.3390/jcm10122734] [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: 05/05/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/17/2022] Open
Abstract
The CORTICO-COP trial showed that eosinophil-guided corticosteroid-sparing treatment for acute exacerbation of chronic obstructive pulmonary disease was non-inferior to standard of care and decreased the accumulated dose of systemic corticosteroids that patients were exposed to by approximately 60%. Smoking status has been shown to affect corticosteroid responsiveness. This post hoc analysis investigated whether eosinophil-guided treatment is non-inferior to conventional treatment in current smokers. The main analysis of current smokers showed no significant difference in the primary endpoint, days alive, and out of hospital within 14 days between the control group (mean, 9.8 days; 95% confidence interval (CI), 8.7-10.8) and the eosinophil-guided group (mean, 8.7 days; 95% CI, 7.5-9.9; p = 0.34). Secondary analyses of the number of exacerbations or deaths, the number of intensive care unit admissions or deaths, lung function improvement, and change in health-related quality of life also showed no significant differences between the two groups. The results of a sensitivity analysis of ex-smokers are consistent with the main analysis. Our results suggest that eosinophil-guided treatment is non-inferior to standard of care in current smokers and ex-smokers. Because data on the impact of smoking status on eosinophil-guided treatments are sparse, more randomised trials are needed to confirm our results.
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16
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Hernández LC, Eraso CC, Ruiz-Duque B, Arranz MA, Martín EM, Calero Acuña C, Lopez-Campos JL. Predictors of Single Bronchodilation Treatment Response for COPD: An Observational Study with the Trace Database Cohort. J Clin Med 2021; 10:jcm10081708. [PMID: 33921051 PMCID: PMC8071403 DOI: 10.3390/jcm10081708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/08/2021] [Accepted: 04/10/2021] [Indexed: 12/26/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) patients constitute a heterogeneous population in terms of treatment response. Our objective was to identify possible predictive factors of response to treatment with single bronchodilation monotherapy in patients diagnosed with COPD. The Time-based Register and Analysis of COPD Endpoints (TRACE; clinicaltrials.gov NCT03485690) is a prospective cohort of COPD patients who have been attending annual visits since 2012. Patients who were kept on a single bronchodilator during the first year of follow-up were selected. The responders were defined according to all of the following variables: any improvement in morning post-dose forced expiratory volume in 1 s or deterioration <100 mL, no change or improvement in dyspnea score, and no occurrence of exacerbations. Significant and plausible variables were analyzed using a proportional hazard Cox regression for single bronchodilator responders. We analyzed 764 cases, of whom 128 (16.8%) were receiving monotherapy with one bronchodilator. Of these, 85 patients (66.4%) were responders. Factors affecting responder status were: female gender (hazard ratio (HR) 0.276; 95% confidence interval (CI) 0.089–0.858), dyslipidemia (HR 0.436; 95%CI 0.202–0.939), not performing regular exercise (HR 0.523; 95%CI 0.254–1.076), active smoking (HR 0.413; 95%CI 0.186–0.920), and treatment adherence (HR 2.527; 95%CI 1.271–5.027). The factors associated with a single bronchodilation response are mainly non-pharmacological interventions and comorbidities.
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Affiliation(s)
- Laura Carrasco Hernández
- Unidad-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, 41013 Sevilla, Spain; (L.C.H.); (C.C.E.); (B.R.-D.); (M.A.A.); (E.M.M.); (C.C.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Candela Caballero Eraso
- Unidad-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, 41013 Sevilla, Spain; (L.C.H.); (C.C.E.); (B.R.-D.); (M.A.A.); (E.M.M.); (C.C.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Borja Ruiz-Duque
- Unidad-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, 41013 Sevilla, Spain; (L.C.H.); (C.C.E.); (B.R.-D.); (M.A.A.); (E.M.M.); (C.C.A.)
| | - María Abad Arranz
- Unidad-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, 41013 Sevilla, Spain; (L.C.H.); (C.C.E.); (B.R.-D.); (M.A.A.); (E.M.M.); (C.C.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Eduardo Márquez Martín
- Unidad-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, 41013 Sevilla, Spain; (L.C.H.); (C.C.E.); (B.R.-D.); (M.A.A.); (E.M.M.); (C.C.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Carmen Calero Acuña
- Unidad-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, 41013 Sevilla, Spain; (L.C.H.); (C.C.E.); (B.R.-D.); (M.A.A.); (E.M.M.); (C.C.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jose Luis Lopez-Campos
- Unidad-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, 41013 Sevilla, Spain; (L.C.H.); (C.C.E.); (B.R.-D.); (M.A.A.); (E.M.M.); (C.C.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence:
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17
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Halpin DMG, Vogelmeier CF, Mezzi K, Gupta P, Kostikas K, Wedzicha JA. Efficacy of indacaterol/glycopyrronium versus salmeterol/fluticasone in current and ex-smokers: a pooled analysis of IGNITE trials. ERJ Open Res 2021; 7:00816-2020. [PMID: 33644225 PMCID: PMC7897898 DOI: 10.1183/23120541.00816-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 11/06/2022] Open
Abstract
Inhaled corticosteroids have proven to be less effective in asthmatic patients who smoke; however, there is limited information on the efficacy of inhaled corticosteroid-containing regimens in COPD patients who continue smoking. We evaluate the differential efficacy of once-daily indacaterol/glycopyrronium 110/50 µg compared with twice-daily salmeterol/fluticasone 50/500 µg in current smokers and ex-smokers with COPD. A pooled analysis of data from ILLUMINATE, LANTERN and FLAME studies was conducted to assess the efficacy of indacaterol/glycopyrronium compared with salmeterol/fluticasone in current smokers and ex-smokers with COPD. Efficacy was assessed in terms of improvements in trough forced expiratory volume in 1 s (FEV1), transition dyspnoea index (TDI) focal score, St George's Respiratory Questionnaire (SGRQ) total score, reduced rescue medication use and exacerbation prevention at 26 weeks after the start of the therapy. In total, 1769 (38%) current smokers and 2848 (62%) ex-smokers were included. Patients treated with indacaterol/glycopyrronium experienced greater improvements in trough FEV1versus salmeterol/fluticasone in both current and ex-smokers (least squares mean treatment difference, 105 mL and 78 mL, respectively). Improvements in TDI focal score, SGRQ total score and reduction in rescue medication use were also greater with indacaterol/glycopyrronium versus salmeterol/fluticasone in current and ex-smokers. Furthermore, indacaterol/glycopyrronium reduced all exacerbations (moderate/severe) compared with salmeterol/fluticasone, irrespective of smoking status. The difference in efficacy in favour of indacaterol/glycopyrronium was more prominent in current smokers in most cases. Indacaterol/glycopyrronium demonstrated greater efficacy versus salmeterol/fluticasone, and the differences were generally more prominent in current smokers suggesting smoking may reduce the effects of salmeterol/fluticasone. In both current smokers and ex-smokers with COPD, indacaterol/glycopyrronium demonstrates greater efficacy than salmeterol/fluticasone but the difference is more prominent in current smokers for most of the evaluated parametershttps://bit.ly/2Ih8Hq3
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Affiliation(s)
- David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Claus F Vogelmeier
- University Medical Centre Giessen and Marburg, member of the German Centre for Lung Research (DZL), Marburg, Germany
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