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Vameghestahbanati M, Kingdom L, Hoffman EA, Kirby M, Allen NB, Angelini E, Bertoni A, Hamid Q, Hogg JC, Jacobs DR, Laine A, Maltais F, Michos ED, Sack C, Sin D, Watson KE, Wysoczanksi A, Couper D, Cooper C, Han M, Woodruff P, Tan WC, Bourbeau J, Barr RG, Smith BM. Airway tree caliber heterogeneity and airflow obstruction among older adults. J Appl Physiol (1985) 2024; 136:1144-1156. [PMID: 38420676 DOI: 10.1152/japplphysiol.00694.2022] [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: 11/15/2022] [Revised: 02/07/2024] [Accepted: 02/22/2024] [Indexed: 03/02/2024] Open
Abstract
Smaller mean airway tree caliber is associated with airflow obstruction and chronic obstructive pulmonary disease (COPD). We investigated whether airway tree caliber heterogeneity was associated with airflow obstruction and COPD. Two community-based cohorts (MESA Lung, CanCOLD) and a longitudinal case-control study of COPD (SPIROMICS) performed spirometry and computed tomography measurements of airway lumen diameters at standard anatomical locations (trachea-to-subsegments) and total lung volume. Percent-predicted airway lumen diameters were calculated using sex-specific reference equations accounting for age, height, and lung volume. The association of airway tree caliber heterogeneity, quantified as the standard deviation (SD) of percent-predicted airway lumen diameters, with baseline forced expired volume in 1-second (FEV1), FEV1/forced vital capacity (FEV1/FVC) and COPD, as well as longitudinal spirometry, were assessed using regression models adjusted for age, sex, height, race-ethnicity, and mean airway tree caliber. Among 2,505 MESA Lung participants (means ± SD age: 69 ± 9 yr; 53% female, mean airway tree caliber: 99 ± 10% predicted, airway tree caliber heterogeneity: 14 ± 5%; median follow-up: 6.1 yr), participants in the highest quartile of airway tree caliber heterogeneity exhibited lower FEV1 (adjusted mean difference: -125 mL, 95%CI: -171,-79), lower FEV1/FVC (adjusted mean difference: -0.01, 95%CI: -0.02,-0.01), and higher odds of COPD (adjusted odds ratio: 1.42, 95%CI: 1.01-2.02) when compared with the lowest quartile, whereas longitudinal changes in FEV1 and FEV1/FVC did not differ significantly. Observations in CanCOLD and SPIROMICS were consistent. Among older adults, airway tree caliber heterogeneity was associated with airflow obstruction and COPD at baseline but was not associated with longitudinal changes in spirometry.NEW & NOTEWORTHY In this study, by leveraging two community-based samples and a case-control study of heavy smokers, we show that among older adults, airway tree caliber heterogeneity quantified by CT is associated with airflow obstruction and COPD independent of age, sex, height, race-ethnicity, and dysanapsis. These observations suggest that airway tree caliber heterogeneity is a structural trait associated with low baseline lung function and normal decline trajectory that is relevant to COPD.
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Affiliation(s)
| | - Leina Kingdom
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
| | - Miranda Kirby
- Department of Physics, Ryerson University, Toronto, Ontario, Canada
| | - Norrina B Allen
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, United States
| | - Elsa Angelini
- Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Medicine, Columbia University, New York, New York, United States
| | - Alain Bertoni
- Department of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina, United States
| | - Qutayba Hamid
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Faculty of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - James C Hogg
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - David R Jacobs
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Andrew Laine
- Department of Medicine, Columbia University, New York, New York, United States
| | - Francois Maltais
- Faculty of Medicine , University of Laval, Laval, Quebec, Canada
| | - Erin D Michos
- Faculty of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Coralynn Sack
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Don Sin
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Karol E Watson
- Department of Medicine, University of California, Los Angeles, California, United States
| | - Artur Wysoczanksi
- Department of Medicine, Columbia University, New York, New York, United States
| | - David Couper
- Department of Biostatistics, University of North Carolina, North Carolina, United States
| | - Christopher Cooper
- Department of Medicine, University of California, Los Angeles, California, United States
| | - Meilan Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Prescott Woodruff
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, United States
| | - Wan C Tan
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean Bourbeau
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - R Graham Barr
- Department of Medicine, Columbia University, New York, New York, United States
| | - Benjamin M Smith
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Columbia University, New York, New York, United States
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2
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Kim EK, Lee E, Park JE, Lee JS, Choi HS, Park B, Sheen SS, Park KJ, Rhee CK, Lee SY, Yoo KH, Park JH. Cardiovascular Events According to Inhaler Therapy and Comorbidities in Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2024; 19:243-254. [PMID: 38269030 PMCID: PMC10806337 DOI: 10.2147/copd.s433583] [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: 08/30/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024] Open
Abstract
Background COPD coexists with many concurrent comorbidities. Cardiovascular complications are deemed to be major causes of death in COPD. Although inhaler therapy is the main therapeutic intervention in COPD, cardiovascular events accompanying inhaler therapy require further investigation. Therefore, this study aimed to investigate new development of cardiovascular events according to each inhaler therapy and comorbidities. Methods This study analyzed COPD patients (age ≥ 40 years, N = 199,772) from the Health Insurance Review and Assessment Service (HIRA) database in Korea. The development of cardiovascular events, from the index date to December 31, 2020, was investigated. The cohort was eventually divided into three arms: the LAMA/LABA group (N = 28,322), the ICS/LABA group (N = 11,812), and the triple group (LAMA/ICS/LABA therapy, N = 6174). Results Multivariable Cox analyses demonstrated that, compared to ICS/LABA therapy, triple therapy was independently associated with the development of ischemic heart disease (HR: 1.22, 95% CI: 1.04-1.43), heart failure (HR: 1.45, 95% CI: 1.14-1.84), arrhythmia (HR: 1.72, 95% CI: 1.41-2.09), and atrial fibrillation/flutter (HR: 2.31, 95% CI: 1.64-3.25), whereas the LAMA/LABA therapy did not show a significant association. Furthermore, emergency room visit during covariate assessment window was independently associated with the development of ischemic heart disease, heart failure, arrhythmia, and atrial fibrillation/flutter (p < 0.05). Conclusion Our data suggest that cardiovascular risk should be considered in COPD patients receiving triple therapy, despite the confounding bias resulting from disparities in each group.
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Affiliation(s)
- Eun Kyung Kim
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Eunyoung Lee
- Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ji Eun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hye Sook Choi
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Bumhee Park
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, Republic of Korea
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Seung Soo Sheen
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kwang Joo Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chin Kook Rhee
- Department of Internal Medicine, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Yeub Lee
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Kwang Ha Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
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3
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Suissa S. Simplifying pharmacotherapy for patients with COPD: a viewpoint. Eur Respir J 2023; 62:2301510. [PMID: 38097204 DOI: 10.1183/13993003.01510-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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4
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Brunton SA, Hogarth DK. Overuse of long-acting β 2-agonist/inhaled corticosteroids in patients with chronic obstructive pulmonary disease: time to rethink prescribing patterns. Postgrad Med 2023; 135:784-802. [PMID: 38032494 DOI: 10.1080/00325481.2023.2284650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality globally. In the major revision of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report, the scientific committee concluded that the use of long-acting β2-agonist/inhaled corticosteroids (LABA/ICS) is not encouraged in patients with COPD. However, current prescribing patterns reveal significant use of LABA/ICS. In this paper, the evidence behind the current practice and the latest treatment recommendations is reviewed. We compare the efficacy and safety of combination therapy with long-acting muscarinic antagonist (LAMA) and LABA vs LABA/ICS and note that LAMA/LABA combinations have reduced the annual rate of moderate/severe exacerbations, delayed the time to first exacerbation, and increased post-dose FEV1 vs ICS-based regimens. The GOLD 2023 report recommends treatment with LABA and LAMA combination (preferably as a single inhaler) in patients with persistent dyspnea, with initiation of ICS in patients based on the symptoms (dyspnea and exercise intolerance as indicated by modified Medical Research Council [mMRC] score ≥ 2 and COPD Assessment Test [CAT™] > 20), blood eosinophil count (≥ 300 cells/µL), and exacerbation history (history of hospitalizations for exacerbations of COPD and ≥ 2 moderate exacerbations per year despite appropriate long-acting bronchodilator maintenance therapy). We describe practical recommendations for primary care physicians to optimize therapy for their patients and prevent overuse of ICS-based regimens. We advocate adherence to current recommendations and a greater focus on effective treatments to successfully control symptoms, minimize exacerbation risk, preserve lung function, maximize patient outcomes, and reduce the burden of drug-related adverse events.
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Affiliation(s)
| | - D Kyle Hogarth
- Pulmonary and Critical Care Medicine, The University of Chicago Medicine, Chicago, IL, USA
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Quint JK, Ariel A, Barnes PJ. Rational use of inhaled corticosteroids for the treatment of COPD. NPJ Prim Care Respir Med 2023; 33:27. [PMID: 37488104 PMCID: PMC10366209 DOI: 10.1038/s41533-023-00347-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/04/2023] [Indexed: 07/26/2023] Open
Abstract
Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.
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Affiliation(s)
- Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK.
| | - Amnon Ariel
- Lung Unit, Emek Medical Center, Afula, Israel
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
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6
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Suissa S. Ten Commandments for Randomized Trials of Pharmacological Therapy for COPD and Other Lung Diseases. COPD 2021; 18:485-492. [PMID: 34468248 DOI: 10.1080/15412555.2021.1968816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The randomized controlled trial is the quintessential scientific tool to evaluate the effectiveness and safety of medications. While early trials of drugs used for the treatment of chronic obstructive pulmonary disease (COPD) and other respiratory diseases were generally unambiguous, more recent studies have been controversial. It has become evident that the conduct, design and analysis of these trials were highly variable and may have been responsible for incoherencies in results and interpretation. With the advent of new studies, the need for guiding principles for the conduct of future randomized trials has become manifest. We describe the concept of the counterfactual principle as it applies to the treatment of patients and to the randomized trial. We then present ten methodological tenets for the design and statistical aspects of randomized controlled trials evaluating the effectiveness of drugs used in the treatment of several respiratory diseases. They include eight study design and two statistical analysis principles: 1) Study question; 2) Intervention; 3) Study population; 4) Blinding; 5) Run-in period; 6) Follow-up; 7) Outcome; 8) Safety; 9) Intent-to-treat; 10) Covariate adjustment. These tenets are described using mainly examples from trials of pharmacological treatments for COPD, as well as some from asthma and idiopathic pulmonary fibrosis, conducted over the last 30 years. The careful application of these principles in the conduct of randomized trials will provide rigorous studies and improve the validity of results. The ensuing clearer interpretation of findings will permit their well-founded contribution to treatment guidelines and optimal clinical management.
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital, and the Departments of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal, Canada
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7
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Triple Therapy versus Dual or Monotherapy with Long-Acting Bronchodilators for Chronic Obstructive Pulmonary Disease. A Systematic Review and Meta-analysis. Ann Am Thorac Soc 2021; 17:1308-1318. [PMID: 32692253 DOI: 10.1513/annalsats.202001-023oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: There is uncertainty on the use of using triple therapy (inhaled corticosteroids/long-acting β-agonist/long-acting muscarinic antagonist) inhaler therapy for patients with chronic obstructive pulmonary disease (COPD), who complain of dyspnea and/or exercise intolerance.Objectives: We conducted a systematic review and meta-analyses to estimate the safety and efficacy of using triple therapy compared with long-acting β-agonist/long-acting muscarinic antagonist dual therapy or monotherapy with a single long-acting bronchodilator in patients with stable COPD who complained of dyspnea and/or exercise intolerance.Methods: A search of MEDLINE, Embase, and the Cochrane Library databases was conducted for randomized controlled trials pertaining to the clinical question. A systematic approach was used to screen, abstract, and critically appraise the studies. The grading of recommendations assessment, development, and evaluation method was applied to rate the certainty/quality of the evidence.Results: Eleven studies were eligible for inclusion (n = 14,145 patients). Pairwise random-effects meta-analysis revealed an increase in risk of pneumonia (relative risk, 1.47; 95% confidence interval [95% CI], 1.20-1.80; P < 0.001) and decreased risk of acute exacerbations of COPD (AECOPDs) (relative risk, 0.75; 95% CI, 0.68-0.82; P < 0.001) with triple therapy compared with treatment with dual and monotherapy long-acting bronchodilator therapy. No significant difference in dyspnea scores (standardized mean difference, 0.09; 95% CI, -0.02 to 0.19; P = 0.09) or risk of hospitalization (rate ratio, 0.78; 95% CI, 0.58-1.06; P = 0.11) was noted. When subgroup analysis based on inhaler class was performed, no significant difference was noted between the groups in any of the critical outcomes studied. For patients with a history of one or more AECOPDs in the past year, triple therapy resulted in 230 fewer AECOPDs and 16 more cases of pneumonia per 1,000 patients.Conclusions: In patients with COPD who complain of dyspnea and/or exercise intolerance, triple therapy is not superior to maintenance long-acting bronchodilator therapy, except in patients with a history of one or more exacerbations in the past year, in whom the benefits of reduction in AECOPD outweigh the increased risk of pneumonia.
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8
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Adatia A, Wahab M, Shahid I, Moinuddin A, Killian KJ, Satia I. Effects of cigarette smoke exposure on pulmonary physiology, muscle strength and exercise capacity in a retrospective cohort with 30,000 subjects. PLoS One 2021; 16:e0250957. [PMID: 34166381 PMCID: PMC8224924 DOI: 10.1371/journal.pone.0250957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 04/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The effects of long-term cigarette smoke exposure on pulmonary physiology and how those effects lead to reduced exercise capacity are not well established. METHODS We retrospectively analyzed the spirometry, single-breath gas transfer (DLCO), peripheral muscle strength, and maximum exercise capacity data in patients referred to McMaster University Medical Centre for cardiopulmonary exercise testing between 2000 and 2012. RESULTS 29,441 subjects underwent CPET and had a recorded smoking history [58% male, mean age 51.1 years (S.D.±19.6), BMI 27.4 kg/m2(±5.8)]. 7081 (24%) were current or former smokers and were divided into 4 categories by packs years (mean ±S.D.): <10 (5.8±3.3), 10-20 (17.1±2.9), 20-30 (27.1±2.8), 30-40 (37.3±2.8), and >40 (53.9±12.8). Patients with greater cigarette smoke exposure had lower expiratory flow rates (FEV1, FEF50, FEF75, PEFR), DLCO, and maximum power output (MPO) during exercise. There was no association between smoke exposure and muscle strength. Modeling MPO (kpm/min) output as a function of demographic and physiologic variables showed that the data are well explained by muscle strength (kg), FEV1 (L), and DLCO (mmHg/min/mL) in similar magnitude (MPO = 42.7*Quads0.34*FEV10.34 * DLCO0.43; r = 0.84). CONCLUSIONS Long-term cigarette smoke exposure is associated with small airway narrowing and impaired diffusion capacity but not with peripheral muscle weakness. The effects of smoking, age, and gender on maximum power output are mediated by reductions in FEV1, muscle strength and DLCO. Exercise capacity in smokers may benefit from therapies targeting all 3 variables.
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Affiliation(s)
- Adil Adatia
- Department of Medicine, McMaster University, Hamilton, Canada
- * E-mail:
| | - Mustafaa Wahab
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Izza Shahid
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Ali Moinuddin
- Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Imran Satia
- Department of Medicine, McMaster University, Hamilton, Canada
- Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, Canada
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9
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Affiliation(s)
- Zhongbo Chen
- Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Zaichun Deng
- Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Qunli Ding
- Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
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10
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Vestbo J. Fixed Triple Therapy in Chronic Obstructive Pulmonary Disease and Survival. Living Better, Longer, or Both? Am J Respir Crit Care Med 2020; 201:1463-1464. [PMID: 32212973 PMCID: PMC7301727 DOI: 10.1164/rccm.202003-0622ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jørgen Vestbo
- Division of Infection, Immunity, and Respiratory MedicineThe University of ManchesterManchester, United Kingdomand.,North West Lung CentreManchester University NHS Foundation TrustManchester, United Kingdom
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11
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Król A, Palmér R, Rondeau V, Rennard S, Eriksson UG, Jauhiainen A. Improving the evaluation of COPD exacerbation treatment effects by accounting for early treatment discontinuations: a post-hoc analysis of randomized clinical trials. Respir Res 2020; 21:158. [PMID: 32571311 PMCID: PMC7310001 DOI: 10.1186/s12931-020-01419-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 06/09/2020] [Indexed: 11/28/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) clinical trials aimed at evaluating treatment effects on exacerbations often suffer from early discontinuations of randomized treatment. Treatment discontinuations imply a loss of information and should ideally be considered in the statistical analysis of trial results, particularly if the discontinuations are related to the disease or treatment itself. Here, we explore this issue by investigating (1) whether there exists an association between the risks of exacerbation and treatment discontinuation in COPD clinical trials and (2) whether disregarding this association can cause bias in exacerbation treatment effect estimates. We focus on the hypothetical estimand, i.e. the treatment effect that would have been observed had all subjects completed the trial as planned. Methods The association between exacerbation and discontinuation risks was analysed by applying a joint frailty (random effect) model – allowing for the simultaneous analysis of multiple types of correlated events – to data from five Phase III-IV COPD clinical trials. Specifically, the impact of the association on exacerbation treatment effect estimates was assessed by comparing the treatment hazard ratios of the joint frailty model to the rate/hazard ratios of two related statistical models (the negative binomial and shared frailty models), which both assume discontinuations to be unrelated to the trial outcome. The models were also compared using simulated data. Results A statistically significant (p < 0.0001), positive association between exacerbation and discontinuation risks was found in all trials. Importantly, simulations confirmed that – with such an association – models disregarding the association risk producing biased results (> 5 percentage point difference in hazard/rate ratio). For some treatment comparisons in the clinical trials, the difference in treatment effect estimates between the joint frailty and the other models was as high as 10–15 percentage points. The difference was affected by the strength of the exacerbation-discontinuation association, the population heterogeneity in exacerbation risk, and the difference in discontinuation rates between treatment arms. Conclusions We have identified an association between the risks of exacerbation and treatment discontinuation in five COPD clinical trials. We recommend using the joint frailty model to account for this association when estimating exacerbation treatment effects, particularly when targeting the hypothetical estimand.
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Affiliation(s)
- Agnieszka Król
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Robert Palmér
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Virginie Rondeau
- Biostatistics Team, INSERM CR1219, University of Bordeaux, Bordeaux, France
| | - Stephen Rennard
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK.,University of Nebraska Medical Center, Omaha, NE, USA
| | - Ulf G Eriksson
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Alexandra Jauhiainen
- BioPharma Early Biometrics and Statistical Innovation, Data Science & AI, BioPharmaceuticals R&D, AstraZeneca, Pepparedsleden 1, SE-431 83, Mölndal, Sweden.
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12
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Hillas G, Papaporfyriou A, Dimakou K, Papaioannou AI. Pharmacological treatment of stable COPD: need for a simplified approach. Postgrad Med 2020; 132:126-131. [DOI: 10.1080/00325481.2019.1706996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- G. Hillas
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. Papaporfyriou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
| | - K. Dimakou
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. I. Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
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13
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Franklin JM, Pawar A, Martin D, Glynn RJ, Levenson M, Temple R, Schneeweiss S. Nonrandomized Real-World Evidence to Support Regulatory Decision Making: Process for a Randomized Trial Replication Project. Clin Pharmacol Ther 2019; 107:817-826. [PMID: 31541454 DOI: 10.1002/cpt.1633] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/17/2019] [Indexed: 12/26/2022]
Abstract
Recent legislation mandates that the US Food and Drug Administration issue guidance regarding when real-world evidence (RWE) could be used to support regulatory decision making. Although RWE could come from randomized or nonrandomized designs, there are significant concerns about the validity of RWE assessing medication effectiveness based on nonrandomized designs. We propose an initiative using healthcare claims data to assess the ability of nonrandomized RWE to provide results that are comparable with those from randomized controlled trials (RCTs). We selected 40 RCTs, and we estimate that approximately 30 attempted replications will be completed after feasibility analyses. We designed an implementation process to ensure that each attempted replication is consistent, transparent, and reproducible. This initiative is the first to systematically evaluate the ability of nonrandomized RWE to replicate multiple RCTs using a structured process. Results from this study should provide insight on the strengths and limitations of using nonrandomized RWE from claims for regulatory decision making.
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Affiliation(s)
- Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Martin
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark Levenson
- Division of Biometrics VII, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Temple
- Office of Drug Evaluation I, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Affiliation(s)
- Samy Suissa
- 1 McGill University Montreal, Canada.,3 Jewish General Hospital Montreal, Canada
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15
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Suissa S, Ariel A. Triple therapy in COPD: only for the right patient. Eur Respir J 2019; 53:53/4/1900394. [PMID: 31000667 DOI: 10.1183/13993003.00394-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Samy Suissa
- Center for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital, and the Deps of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal, QC, Canada
| | - Amnon Ariel
- Lung Unit, Emek Medical Center, Clalit Healthcare Services, Afula, Israel
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16
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Vestbo J, Dransfield M, Anderson JA, Brook RD, Calverley PMA, Celli BR, Cowans NJ, Crim C, Martinez F, Newby DE, Yates J, Lange P. Impact of pre-enrolment medication use on clinical outcomes in SUMMIT. ERJ Open Res 2019; 5:00203-2018. [PMID: 30815468 PMCID: PMC6387990 DOI: 10.1183/23120541.00203-2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/19/2018] [Indexed: 11/07/2022] Open
Abstract
In mortality trials including patients with COPD and heightened cardiovascular risk, patients' treatments before entering the trial may affect the effects of inhaled medications during the studyhttp://ow.ly/WRRb30nwyIE The impact of prior treatment on results of clinical trials in chronic obstructive pulmonary disease (COPD) has been debated. We used data from the Study to Understand Mortality and Morbidity in COPD Trial to examine the impact of prior treatment on the effects of randomised study drugs on mortality and exacerbations. We used data on 16 417 patients with moderate COPD and heightened cardiovascular risk and information on prior medications to examine the effects of fluticasone furoate (FF), vilanterol (VI) and combined FF/VI compared to placebo on moderate and severe exacerbation as well as mortality. The study was event-driven with a median study exposure of 1.8 years. This study was registered with ClinicalTrials.gov, number NCT01313676. There were no consistent associations between treatment prior to study entry and the effects of FF, VI or FF/VI on exacerbations during the study. However, patients taking inhaled corticosteroids and one or more bronchodilators prior to study entry seemed to have a better effect of active treatments than of placebo on mortality (hazard ratio for FF/VI 0.65, 95% CI 0.48–0.89). Survival in those randomised to placebo was independent of treatment prior to study enrolment. Prior treatment appears to affect treatment effects on mortality but not exacerbations in a randomised controlled trial of patients with COPD and heightened cardiovascular risk.
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Affiliation(s)
- Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK.,North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mark Dransfield
- Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Robert D Brook
- University of Michigan Health System, Ann Arbor, MI, USA
| | - Peter M A Calverley
- University of Liverpool, Dept of Medicine, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK
| | - Bartolome R Celli
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Courtney Crim
- Research and Development, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Fernando Martinez
- University of Michigan Health System, Ann Arbor, MI, USA.,Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Julie Yates
- Research and Development, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Peter Lange
- Dept of Public Health, Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark.,Medical Unit, Respiratory Section, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
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17
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Gregoriano C, Dieterle T, Breitenstein AL, Dürr S, Baum A, Maier S, Arnet I, Hersberger KE, Leuppi JD. Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial. Respir Res 2018; 19:237. [PMID: 30509268 PMCID: PMC6276152 DOI: 10.1186/s12931-018-0936-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/12/2018] [Indexed: 12/31/2022] Open
Abstract
Background The burden of asthma and COPD among patients is high and people affected are frequently hospitalized due to exacerbations. There are numerous reasons for the lack of disease control in asthma and COPD patients. It is associated with non-adherence to guidelines on the part of the health care provider and with poor inhalation technique and/or non-adherence to the prescribed treatment plan by the patient. This study aims to present data on inhaler technique and its impact on quality of life (QoL) and symptom control in a typical population of patients with chronic lung disease from a randomized controlled trial on medication adherence. Methods For this cross-sectional analysis, 165 asthma and COPD patients were analyzed. Correct application of inhaler devices was tested using pre-defined checklists for each inhaler type. QoL and symptom control were investigated using COPD Assessment Test (CAT) and Asthma Control Test (ACT). Spirometry was used to measure forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Results Overall, incorrect inhalation technique ranged from 0 to 53% depending on the type of inhaler. COPD patients with incorrect device application had a higher CAT sum score compared to those with a correct device application (P = .02). Moreover, COPD patients with incorrect device application were more likely to suffer from cough (P = .03) and were more breathless while walking uphill or a flight of stairs (P = .02). While there was no significance found in asthma patients, COPD patients who used their devices correctly had a significantly better mean FEV1% predicted at baseline compared to those who applied their devices incorrectly (P = .04). Conclusions Correct inhalation of prescribed medication is associated with improved health status and lung function. These findings should encourage health professionals to provide instructions on correct inhalation technique and to regularly re-evaluate the patients’ inhalation technique. Trial registration ClinicalTrials.gov: NCT0238672, Registered 14 February 2014.
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Affiliation(s)
- Claudia Gregoriano
- University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse 26, CH - 4410, Liestal, Switzerland. .,Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.
| | - Thomas Dieterle
- University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse 26, CH - 4410, Liestal, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Anna-Lisa Breitenstein
- University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse 26, CH - 4410, Liestal, Switzerland
| | - Selina Dürr
- University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse 26, CH - 4410, Liestal, Switzerland
| | - Amanda Baum
- University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse 26, CH - 4410, Liestal, Switzerland
| | - Sabrina Maier
- University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse 26, CH - 4410, Liestal, Switzerland
| | - Isabelle Arnet
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Kurt E Hersberger
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Jörg D Leuppi
- University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse 26, CH - 4410, Liestal, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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18
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Kim V, Aaron SD. What is a COPD exacerbation? Current definitions, pitfalls, challenges and opportunities for improvement. Eur Respir J 2018; 52:13993003.01261-2018. [PMID: 30237306 DOI: 10.1183/13993003.01261-2018] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/12/2018] [Indexed: 01/02/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic illness that can be periodically punctuated by exacerbations, characterised by acute worsening of symptoms, including increased dyspnoea, cough, sputum production and sputum purulence. COPD exacerbations are common and have important clinical and economic consequences, including lost work productivity, increased utilisation of healthcare resources, temporary or permanent reductions in lung function and exercise capacity, hospitalisation, and sometimes death. Over the past two decades, clinicians and researchers have broadened their treatment goals for COPD to extend beyond improving lung function and symptoms, and have begun to address the importance of preventing and reducing exacerbations. However, despite the best efforts of clinicians and guideline committees, current definitions of COPD exacerbations are imperfect and fraught with problems. The cardinal symptoms of a COPD exacerbation are nonspecific and can result from acute cardiorespiratory illnesses other than COPD. A proposed definition, which may be more specific than current definitions, suggests that COPD exacerbation be defined as an acute or subacute worsening of dyspnoea (≥5 on a visual analogue scale that ranges from 0 to 10) sometimes but not necessarily accompanied by increased cough, sputum volume and/or sputum purulence. Necessary laboratory criteria for an exacerbation include oxygen desaturation ≤4% below that of stable state, elevated levels of circulating blood neutrophils or eosinophils (≥9000 neutrophils·mm-3 or ≥2% blood eosinophils) and elevated C-reactive protein (≥3 mg·L-1), without evidence of pneumonia or pulmonary oedema on chest radiography and with negative laboratory test results for other aetiologies. Herein, we discuss the current state of the art with respect to how we define COPD exacerbations, associated pitfalls and challenges, and opportunities for improvement.
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Affiliation(s)
- Victor Kim
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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19
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Suissa S, Dell'Aniello S, Ernst P. Comparative effectiveness of LABA-ICS versus LAMA as initial treatment in COPD targeted by blood eosinophils: a population-based cohort study. THE LANCET RESPIRATORY MEDICINE 2018; 6:855-862. [PMID: 30343028 DOI: 10.1016/s2213-2600(18)30368-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Long-acting β2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) are the recommended initial maintenance treatment for chronic obstructive pulmonary disease (COPD), with almost all LABAs dispensed in fixed combination with inhaled corticosteroids (LABA-ICS). We compared the effectiveness and safety of LABA-ICS versus LAMA treatment initiation as a function of blood eosinophilia, a potential biomarker of ICS effectiveness, in a real-world setting. METHODS In this population-based cohort study, we identified a cohort of patients with COPD initiating treatment with a LAMA or LABA-ICS during 2002-15, age 55 years or older, from the UK's Clinical Practice Research Datalink. We excluded patients who initiated treatment with both bronchodilators on the same date. All patients required at least 1 year of medical history and a measure of blood eosinophil concentration before cohort entry, defined by the date of the first cohort-defining bronchodilator prescription. Patients initiating a LAMA were matched on high-dimensional propensity scores with patients initiating a LABA-ICS. They were followed up for 1 year for the occurrence of a moderate or severe COPD exacerbation and for severe pneumonia. Sensitivity analyses included, among others, repeating the analysis among patients with two blood eosinophil concentration measures and stratification by concurrent asthma and previous exacerbations. FINDINGS The base cohort included 539 643 patients with a prescription for LABAs or LAMAs from Jan 1, 2002, to Dec 31, 2015, of whom 18 500 were initiated on LABA-ICS and 13 870 on LAMAs. Propensity score analysis resulted in 12 366 initiators of LAMAs (mainly tiotropium) matched to 12 366 initiators of LABA-ICS. The hazard ratio (HR) of COPD exacerbation associated with LABA-ICS initiation, relative to LAMA initiation, was 0·95 (95% CI 0·90-1·01). In patients with blood eosinophil concentrations of less than 2% of white blood cell count, the HR was 1·03 (95% CI 0·93-1·13) and for those with eosinophil concentrations of 2-4%, the HR was 1·00 (0·91-1·10). For patients with eosinophil concentrations of more than 4%, the HR was 0·79 (0·70-0·88). The incidence of pneumonia increased with LABA-ICS initiation (HR 1·37 [95% CI 1·17-1·60]) and was similar across all eosinophil concentrations. Sensitivity analyses were consistent with these findings, but the incidence of exacerbation with LABA-ICS among the 2766 (11%) of all 24 732 patients with two or more COPD exacerbations during the baseline year was marginally lower (HR 0·87 [95% CI 0·79-0·97]). INTERPRETATION In this real-world, clinical practice, observational study, initial COPD treatment with LABA-ICS inhalers was only more effective than with LAMAs in patients with high blood eosinophil concentrations (>4%) or counts (>300 cells per μL) and possibly in frequent exacerbators. Because of the increased risk of pneumonia associated with the ICS component, initiation with a LAMA should be preferred in patients with blood eosinophil concentrations of less than 4%. FUNDING Canadian Institutes of Health Research, Canadian Foundation for Innovation.
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada; Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada; Department of Medicine, McGill University, Montreal, QC H3T 1E2, Canada.
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada; Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada; Department of Medicine, McGill University, Montreal, QC H3T 1E2, Canada
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20
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Rabe KF, Hurst JR, Suissa S. Cardiovascular disease and COPD: dangerous liaisons? Eur Respir Rev 2018; 27:27/149/180057. [PMID: 30282634 DOI: 10.1183/16000617.0057-2018] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β2-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.
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Affiliation(s)
- Klaus F Rabe
- Dept of Medicine, University of Kiel, Kiel, Germany .,Lung Clinic Großhansdorf, Airway Research Center North (ARCN), Groβhansdorf, Germany
| | - John R Hurst
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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21
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Celli B, Anderson JA, Brook R, Calverley P, Crim C, Holmes AP, Martinez FJ, Newby DE, Yates J, Vestbo J. Long-Acting β-Agonist/Inhaled Corticosteroid in Patients with Chronic Obstructive Pulmonary Disease with Cardiovascular Disease or Risk: A Factorial Analysis of the SUMMIT Clinical Trial. Am J Respir Crit Care Med 2018; 197:1641-1644. [DOI: 10.1164/rccm.201710-2052le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | - Courtney Crim
- GlaxoSmithKlineResearch Triangle Park, North Carolina
| | | | | | | | - Julie Yates
- GlaxoSmithKlineResearch Triangle Park, North Carolina
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22
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Affiliation(s)
- Samy Suissa
- From the Center for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, and the Departments of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal (S.S.)
| | - Jeffrey M Drazen
- From the Center for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, and the Departments of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal (S.S.)
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23
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Calverley PM, Anzueto AR, Dusser D, Mueller A, Metzdorf N, Wise RA. Treatment of exacerbations as a predictor of subsequent outcomes in patients with COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1297-1308. [PMID: 29719385 PMCID: PMC5922419 DOI: 10.2147/copd.s153631] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rationale Exacerbations of COPD are managed differently, but whether treatment of one exacerbation predicts the likelihood of subsequent events is unknown. Objective We examined whether the treatment given for exacerbations predicted subsequent outcomes. Methods This was a post-hoc analysis of 17,135 patients with COPD from TIOtropium Safety and Performance In Respimat® (TIOSPIR®). Patients treated with tiotropium with one or more moderate to severe exacerbations on study were analyzed using descriptive statistics, logistic and Cox regression analysis, and Kaplan–Meier plots. Results Of 8,061 patients with moderate to severe exacerbation(s), demographics were similar across patients with exacerbations treated with antibiotics and/or steroids or hospitalization. Exacerbations treated with systemic corticosteroids alone or in combination with antibiotics had the highest risk of subsequent exacerbation (HR: 1.21, P=0.0004 and HR: 1.33, P<0.0001, respectively), and a greater risk of having a hospitalized (severe) exacerbation (HR: 1.59 and 1.63, P<0.0001, respectively) or death (HR: 1.50, P=0.0059 and HR: 1.47, P=0.0002, respectively) compared with exacerbations treated with antibiotics alone. Initial hospitalization led to the highest risk of subsequent hospitalization (all-cause or COPD related [severe exacerbation], HR: 3.35 and 4.31, P<0.0001, respectively) or death (all-cause or COPD related, HR: 3.53 and 5.54, P<0.0001, respectively) versus antibiotics alone. Conclusion These data indicate that the way exacerbations are treated initially is a useful guide to the patient’s subsequent clinical course. Factors that clinicians consider when making treatment choices require further clarification.
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Affiliation(s)
- Peter Ma Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Antonio R Anzueto
- Pulmonary/Critical Care, University of Texas and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Daniel Dusser
- Department of Pneumology, Hôpital Cochin, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Achim Mueller
- Biostatistics and Data Sciences Europe, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Norbert Metzdorf
- Respiratory Medicine, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Ariel A, Altraja A, Belevskiy A, Boros PW, Danila E, Fležar M, Koblizek V, Fridlender ZG, Kostov K, Krams A, Milenkovic B, Somfay A, Tkacova R, Tudoric N, Ulmeanu R, Valipour A. Inhaled therapies in patients with moderate COPD in clinical practice: current thinking. Int J Chron Obstruct Pulmon Dis 2017; 13:45-56. [PMID: 29317810 PMCID: PMC5743110 DOI: 10.2147/copd.s145573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COPD is a complex, heterogeneous condition. Even in the early clinical stages, COPD carries a significant burden, with breathlessness frequently leading to a reduction in exercise capacity and changes that correlate with long-term patient outcomes and mortality. Implementation of an effective management strategy is required to reduce symptoms, preserve lung function, quality of life, and exercise capacity, and prevent exacerbations. However, current clinical practice frequently differs from published guidelines on the management of COPD. This review focuses on the current scientific evidence and expert opinion on the management of moderate COPD: the symptoms arising from moderate airflow obstruction and the burden these symptoms impose, how physical activity can improve disease outcomes, the benefits of dual bronchodilation in COPD, and the limited evidence for the benefits of inhaled corticosteroids in this disease. We emphasize the importance of maximizing bronchodilation in COPD with inhaled dual-bronchodilator treatment, enhancing patient-related outcomes, and enabling the withdrawal of inhaled corticosteroids in COPD in well-defined patient groups.
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Affiliation(s)
- Amnon Ariel
- Emek Medical Center, Clalit Healthcare Services, Afula, Israel
| | - Alan Altraja
- Department of Pulmonary Medicine, University of Tartu
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Andrey Belevskiy
- Department of Pulmonology, Russian National Research Medical University, Moscow, Russia
| | - Piotr W Boros
- Lung Pathophysiology Department, National TB and Lung Diseases Research Institute, Warsaw, Poland
| | - Edvardas Danila
- Clinic of Infectious Chest Diseases, Dermatovenereology, and Allergology, Vilnius University, Centre of Pulmonology and Allergology, Vilnius University Hospital, Vilnius, Lithuania
| | - Matjaz Fležar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Vladimir Koblizek
- Department of Pneumology, University Hospital, Hradec Králové, Czech Republic
| | - Zvi G Fridlender
- Institute of Pulmonary Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Kosta Kostov
- Clinic of Pulmonary Diseases, Military Medical Academy, Sofia, Bulgaria
| | - Alvils Krams
- Medical Faculty of Latvian University, Riga East University Hospital, Riga, Latvia
| | - Branislava Milenkovic
- Clinic for Pulmonary Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Attila Somfay
- Department of Pulmonology, University of Szeged, Deszk, Hungary
| | - Ruzena Tkacova
- Department of Respiratory Medicine and Tuberculosis, Faculty of Medicine, PJ Safarik University, Košice, Slovakia
| | - Neven Tudoric
- School of Medicine, Dubrava University Hospital, Zagreb, Croatia
| | | | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
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25
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Calverley PMA, Magnussen H, Miravitlles M, Wedzicha JA. Triple Therapy in COPD: What We Know and What We Don't. COPD 2017; 14:648-662. [DOI: 10.1080/15412555.2017.1389875] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Centre for Lung Research, Grosshansdorf, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Jadwiga A. Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
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26
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Franklin JM, Schneeweiss S. When and How Can Real World Data Analyses Substitute for Randomized Controlled Trials? Clin Pharmacol Ther 2017; 102:924-933. [PMID: 28836267 DOI: 10.1002/cpt.857] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 12/13/2022]
Abstract
Regulators consider randomized controlled trials (RCTs) as the gold standard for evaluating the safety and effectiveness of medications, but their costs, duration, and limited generalizability have caused some to look for alternatives. Real world evidence based on data collected outside of RCTs, such as registries and longitudinal healthcare databases, can sometimes substitute for RCTs, but concerns about validity have limited their impact. Greater reliance on such real world data (RWD) in regulatory decision making requires understanding why some studies fail while others succeed in producing results similar to RCTs. Key questions when considering whether RWD analyses can substitute for RCTs for regulatory decision making are WHEN one can study drug effects without randomization and HOW to implement a valid RWD analysis if one has decided to pursue that option. The WHEN is primarily driven by externalities not controlled by investigators, whereas the HOW is focused on avoiding known mistakes in RWD analyses.
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Affiliation(s)
- Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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27
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital, Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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28
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Miravitlles M, Anzueto A, Jardim JR. Optimizing bronchodilation in the prevention of COPD exacerbations. Respir Res 2017; 18:125. [PMID: 28633665 PMCID: PMC5477752 DOI: 10.1186/s12931-017-0601-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/29/2017] [Indexed: 02/03/2023] Open
Abstract
The natural disease course of chronic obstructive pulmonary disease (COPD) is often punctuated by exacerbations: acute events of symptom worsening associated with significant morbidity and healthcare resource utilization; reduced quality of life; and increased risk of hospitalization and death. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend that patients at risk of exacerbations (GOLD Groups C and D) receive a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA)/LAMA combination, respectively, as preferred initial treatments. The latter recommendation is based on recent trial evidence demonstrating the superior efficacy of a fixed-dose LABA/LAMA over an inhaled corticosteroid (ICS)/LABA in exacerbation prevention. ICS in combination with a LABA is also indicated for prevention of exacerbations, but the use of ICS is associated with an increased risk of adverse events such as pneumonia, and offers limited benefits beyond those provided by LABA or LAMA monotherapy. In this review, we examine evidence from a number of pivotal studies of LABAs and LAMAs, administered as monotherapy or as part of dual or triple combination therapy, with a specific focus on their effect on exacerbations. We also discuss a new proposed treatment paradigm for the management of COPD that takes into account this recent evidence and adopts a more cautious approach to the use of ICS. In alignment with GOLD 2017, we suggest that ICS should be reserved for patients with concomitant asthma or in whom exacerbations persist despite treatment with LABA/LAMA.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antonio Anzueto
- University of Texas Health Science Center, and South Texas Veterans Health Care System, San Antonio, TX USA
| | - José R. Jardim
- Respiratory Division, Escola Paulista de Medicina / Federal University de São Paulo, São Paulo, Brazil
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29
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Eriksson G, Calverley PM, Jenkins CR, Anzueto AR, Make BJ, Lindberg M, Fagerås M, Postma DS. The effect of COPD severity and study duration on exacerbation outcome in randomized controlled trials. Int J Chron Obstruct Pulmon Dis 2017; 12:1457-1468. [PMID: 28553098 PMCID: PMC5440002 DOI: 10.2147/copd.s130713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background When discontinuation in COPD randomized controlled trials (RCTs) is unevenly distributed between treatments (differential dropout), the capacity to demonstrate treatment effects may be reduced. We investigated the impact of the time of differential dropout on exacerbation outcomes in RCTs, in relation to study duration and COPD severity. Methods A post hoc analysis of 2,345 patients from three RCTs of 6- and 12-month duration was performed to compare budesonide/formoterol and formoterol in moderate, severe, and very severe COPD. Outcomes were exacerbation rate, time-to-first exacerbation, or discontinuation; patients were stratified by disease severity. Outcomes were studied by censoring data monthly from 1 to 12 months. Results In patients treated with budesonide/formoterol, annualized exacerbation rates (AERs) were comparable for each study duration (rate ratio [RR] =0.6). With formoterol, the AER decreased with study duration (RR =1.20 at 1 month to RR =0.86 at 12 months). There was a treatment-related difference in exacerbation rates of 45%–48% for shorter study durations (≤4 months) and 27% for 12-month duration. This treatment-related difference in exacerbation rates was comparable for the three disease severities in studies ≤4 months (range: 39%–51%), but this difference decreased with longer study durations, especially in more severe groups (22% and 29% at 12 months). There were fewer discontinuations with budesonide/formoterol; the treatment-related difference in time-to-first discontinuation decreased by study duration (35%, 30%, 26%, and 22% at 3, 6, 9, and 12 months, respectively). Numbers of differential dropouts increased with increasing disease severity, being greatest during second, third, and fourth months. Conclusions COPD severity and study duration impact exacerbation as an outcome in double-blind RCTs. This effect is most obvious in patients with severe/very severe COPD and in studies that are longer than 4 months. Early differential dropout particularly impacts study outcome, producing a “healthy survivor effect,” which reduces estimations of treatment impact on exacerbations.
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Affiliation(s)
- Göran Eriksson
- Department of Respiratory Medicine and Allergology, University Hospital, Lund, Sweden
| | - Peter M Calverley
- Pulmonary and Rehabilitation Research Group, University Hospital Aintree, Liverpool, UK
| | - Christine R Jenkins
- Concord Clinical School, University of Sydney.,The George Institute for Global Health, Sydney, Australia
| | - Antonio R Anzueto
- Department of Pulmonary Medicine and Critical Care, University of Texas Health Sciences Center and South Texas Veterans' Health Care System, San Antonio, Texas
| | - Barry J Make
- Division of Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Denver, Colorado, USA
| | | | | | - Dirkje S Postma
- Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, GRIAC Research Institute, University of Groningen, Groningen, the Netherlands
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30
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Morjaria JB, Rigby A, Morice AH. Inhaled Corticosteroid use and the Risk of Pneumonia and COPD Exacerbations in the UPLIFT Study. Lung 2017; 195:281-288. [PMID: 28255905 PMCID: PMC5437199 DOI: 10.1007/s00408-017-9990-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/20/2017] [Indexed: 01/18/2023]
Abstract
RATIONALE Unlike many other COPD studies, the 4-year UPLIFT trial permitted inhaled corticosteroid (ICS) use during run-in and treatment phases. This provided the opportunity to prospectively observe the continuing effects of ICS on respiratory events in closely observed COPD population. OBJECTIVES We aimed to determine rate and number of episodes of pneumonia and exacerbations of COPD in patients entering the study on no ICS, fluticasone proprionate (FP), and other ICS. METHODS The UPLIFT dataset was examined retrospectively, and patients were divided into three groups based on their medications at entry: no ICS, FP and other ICS. Poisson regression was used to compare the frequency of respiratory adverse events. MEASUREMENTS AND MAIN RESULTS At entry, the groups were well matched apart from a higher FEV1% predicted (38 vs. 41%; ICS vs. no ICS, respectively) and prevalence of current smoking (26 vs. 36%; ICS vs. no ICS, respectively). Incidence rates of pneumonia were significantly higher in patients taking ICS compared to no ICS (0.068 vs. 0.056 respectively; p = 0.012). When the FP group was compared to the other ICS, the event rate was even higher (0.077 vs. 0.058, respectively; p < 0.001). COPD exacerbations were more frequent in patients taking ICS, with significantly greater rate in the FP group compared to that seen with other ICS (0.93 vs. 0.84 respectively; p = 0.013). CONCLUSIONS ICS use was associated an increase in respiratory adverse event rates, but whether this was due to more severe illness at entry is unknown. In subgroup analysis, the excess of morbidity in the ICS group appeared to be mainly associated with those receiving FP at randomisation.
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Affiliation(s)
- Jaymin B Morjaria
- Centre for Cardiovascular & Metabolic Research, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, HU6 5JQ, UK.,Department of Respiratory Medicine, Royal Brompton & Harefield NHS Trust, Harefield Hospital, Hill End road, Harefield, UB9 6JH, UK
| | - Alan Rigby
- Centre for Cardiovascular & Metabolic Research, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, HU6 5JQ, UK
| | - Alyn H Morice
- Centre for Cardiovascular & Metabolic Research, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, HU6 5JQ, UK.
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Lee HW, Kim HJ, Lee CH. The impact of olodaterol on the risk of mortality and serious adverse events: a systematic review and meta-analysis. Br J Clin Pharmacol 2017; 83:1166-1175. [PMID: 27957746 DOI: 10.1111/bcp.13210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/21/2016] [Accepted: 12/09/2016] [Indexed: 01/27/2023] Open
Abstract
AIMS Olodaterol is a novel inhaled long-acting β2 -agonist (LABA) that showed efficacy as a bronchodilator for patients with chronic obstructive pulmonary disease (COPD) and asthma. However, it is unclear whether olodaterol reduces mortality; the safety issues of olodaterol have not been fully evaluated. METHODS Randomized controlled trials comparing olodaterol with placebo for patients with COPD or asthma, which evaluated mortality or serious adverse events, were included. Eighteen trials reporting mortality and 26 trials reporting nonfatal serious adverse events were included. RESULTS Inhaled olodaterol did not reduce the risk of mortality (Peto fixed OR 1.31; 95% CI 0.90-1.89) and had no significant impacts on nonfatal serious adverse events (Peto fixed OR 1.03; 95% CI 0.91-1.15). CONCLUSIONS Inhaled olodaterol has no impact on mortality risk in clinical trials conducted on patients with COPD and asthma. However, the interpretation is limited by a high OR (1.31) and a wide CI that includes the hazardous effect. We could not find any relationship between inhaled olodaterol use and nonfatal serious adverse events.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
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32
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Slejko JF, Willke RJ, Ribbing J, Milligan P. Translating Pharmacometrics to a Pharmacoeconomic Model of COPD. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:1026-1032. [PMID: 27987629 DOI: 10.1016/j.jval.2016.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/24/2016] [Accepted: 07/26/2016] [Indexed: 05/24/2023]
Abstract
BACKGROUND A model-based meta-analysis (MBMA) is a type of meta-regression that uses nonlinear mixed-effects models estimated on trial-level data to relate patient and trial characteristics, dosing, biomarkers, and outcomes of treatment. OBJECTIVES To use a pharmacometric MBMA within a pharmacoeconomic model of chronic obstructive pulmonary disease (COPD). METHODS A Markov microsimulation model was developed to estimate monthly changes in the key disease severity metrics of COPD (forced expiratory volume in 1 second [FEV1] and exacerbations) to compare a hypothetical drug that increases FEV1 to usual care. The MBMA was used to predict a baseline exacerbation rate in a group of actual trial patients, given their known baseline FEV1. The hypothetical drug increased FEV1, thereby decreasing individuals' predicted exacerbation rates. Individual patient simulations allowed stochastic changes in monthly FEV1 decline. RESULTS In a sample of 1097 trial patients with a mean FEV1 of 50%, the MBMA predicted 0.93 exacerbations per year on average. The exacerbation rate ranged from 0.52 to 1.3 per year across moderate and severe patient subgroups. A hypothetical anti-inflammatory drug that increased FEV1 by 50 ml decreased exacerbations by 26%. Given a simplified estimation of costs and quality-adjusted life-years (QALYs) associated with COPD, a drug with a 50-ml increase priced at €35/mo had an incremental cost-effectiveness ratio ranging from €13,000/QALY to approximately €207,000/QALY across patient severity subgroups. CONCLUSIONS The synergistic aspects of MBMA and pharmacoeconomic modeling are highlighted in this hypothetical example. Markov microsimulation modeling allows the finer predictions of MBMA to inform parameters. Such an approach has utility in both early-phase cost-effectiveness estimations and trial design.
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Affiliation(s)
- Julia F Slejko
- Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA.
| | - Richard J Willke
- International Society for Pharmacoeconomics and Outcomes Research, Lawrenceville, NJ, USA
| | | | - Peter Milligan
- Global Clinical Pharmacology, Pfizer, Sandwich, United Kingdom
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Yawn BP, Suissa S, Rossi A. Appropriate use of inhaled corticosteroids in COPD: the candidates for safe withdrawal. NPJ Prim Care Respir Med 2016; 26:16068. [PMID: 27684954 PMCID: PMC5042192 DOI: 10.1038/npjpcrm.2016.68] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 07/11/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023] Open
Abstract
International guidance on chronic obstructive pulmonary disease (COPD) management recommends the use of inhaled corticosteroids (ICS) in those patients at increased likelihood of exacerbation. In spite of this guidance, ICS are prescribed in a large number of patients who are unlikely to benefit. Given the evidence of the risks associated with ICS and the limited indications for their use, there is interest in understanding the effects of withdrawing ICS when prescribed inappropriately. In this review, we discuss the findings of large ICS withdrawal trials, with primary focus on the more recent trials using active comparators. Data from these trials indicate that ICS may be withdrawn without adverse impact on exacerbation risk and patient-reported outcomes in patients with moderate COPD and no history of frequent exacerbations. Considering the safety concerns associated with ICS use, these medications should be withdrawn in patients for whom they are not recommended, while maintaining adequate bronchodilator therapy.
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Affiliation(s)
- Barbara P Yawn
- Department of Family and Community Health, University of Minnesota, Rochester, MN, USA
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Department of Epidemiology and Biostatistics and Department of Medicine, McGill University, Montreal, QC, Canada
| | - Andrea Rossi
- Pulmonary Unit, University and General Hospital, Verona, Italy
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34
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Kaplan AG. Applying the wisdom of stepping down inhaled corticosteroids in patients with COPD: a proposed algorithm for clinical practice. Int J Chron Obstruct Pulmon Dis 2015; 10:2535-48. [PMID: 26648711 PMCID: PMC4664433 DOI: 10.2147/copd.s93321] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Current guidelines for the management of chronic obstructive pulmonary disease (COPD) recommend limiting the use of inhaled corticosteroids (ICS) to patients with more severe disease and/or increased exacerbation risk. However, there are discrepancies between guidelines and real-life practice, as ICS are being overprescribed. In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS. Several studies sought out to determine the effects of withdrawing ICS in patients with COPD. Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms. However, these studies were fraught with numerous methodological limitations. Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients. Of these, the WISDOM (Withdrawal of Inhaled Steroids During Optimized Bronchodilator Management) trial was the largest and first to examine stepwise withdrawal of ICS in patients with COPD receiving maintenance therapy of long-acting bronchodilators (ie, tiotropium and salmeterol). Even with therapy being in line with the current guidelines, the findings of the WISDOM trial indicate that not all patients benefit from including ICS in their treatment regimen. Indeed, only certain COPD phenotypes seem to benefit from ICS therapy, and validated markers that predict ICS response are urgently warranted in clinical practice. Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal. In addition to providing a review of the aforementioned, this perspective article proposes an algorithm for the stepwise withdrawal of ICS in real-life clinical practice.
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Affiliation(s)
- Alan G Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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35
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Santus P, Radovanovic D, Paggiaro P, Papi A, Sanduzzi A, Scichilone N, Braido F. Why use long acting bronchodilators in chronic obstructive lung diseases? An extensive review on formoterol and salmeterol. Eur J Intern Med 2015; 26:379-84. [PMID: 26049917 DOI: 10.1016/j.ejim.2015.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/27/2015] [Accepted: 05/01/2015] [Indexed: 10/23/2022]
Abstract
Long-acting β2-adrenoceptor agonists, formoterol and salmeterol, represent a milestone in the treatments of chronic obstructive lung diseases. Although no specific indications concerning the choice of one molecule rather than another are provided by asthma and COPD guidelines, they present different pharmacological properties resulting in distinct clinical employment possibilities. In particular, salmeterol has a low intrinsic efficacy working as a partial receptor agonist, while formoterol is a full agonist with high intrinsic efficacy. From a clinical perspective, in the presence of low β2-adrenoceptors availability, like in inflamed airways, a full agonist can maintain its bronchodilatory and non-smooth muscle activities while a partial agonist may be less effective. Furthermore, formoterol presents a faster onset of action than salmeterol. This phenomenon, combined with the molecule safety profile, leads to a prompt amelioration of the symptoms, and allows using this drug in asthma as an "as needed" treatment in patients already on regular treatment. The fast onset of action and the full agonism of formoterol need to be considered in order to select the best pharmacological treatment of asthma and COPD.
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Affiliation(s)
- P Santus
- Dipartimento di Scienze della Salute. Pneumologia Riabilitativa Fondazione Salvatore Maugeri, Istituto Scientifico di Milano-IRCCS. Università degli Studi di Milano, Italy
| | - D Radovanovic
- Dipartimento di Scienze della Salute. Pneumologia Riabilitativa Fondazione Salvatore Maugeri, Istituto Scientifico di Milano-IRCCS. Università degli Studi di Milano, Italy
| | - P Paggiaro
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Italy
| | - A Papi
- Respiratory Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - A Sanduzzi
- Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University of Naples, Italy
| | - N Scichilone
- Department of Internal Medicine, Section of Pulmonology (DIBIMIS), University of Palermo, Italy
| | - F Braido
- Allergy and Respiratory Diseases Clinic, DIMI, University of Genoa, IRCS AOU San Martino-IST, Genoa, Italy.
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Horita N, Kaneko T. Role of combined indacaterol and glycopyrronium bromide (QVA149) for the treatment of COPD in Japan. Int J Chron Obstruct Pulmon Dis 2015; 10:813-22. [PMID: 25960646 PMCID: PMC4410821 DOI: 10.2147/copd.s56067] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Once-daily dual-bronchodilator therapy with combined indacaterol and glycopyrronium bromide in one device (Ultibro, Breezhaler), often called QVA149, was first approved in 2013 in Japan and Europe. As of November 2014, more than 40 countries had approved this medication except for the USA. This is the first dual bronchodilator in one device. Now, the Breezhaler is the only device that can provide long-acting muscarinic antagonist (glycopyrronium bromide), long-acting beta agonist (indacaterol), and a combination of the two medications (QVA149). The choice among the three medications allows a patient to use the same inhalation device even when the regimen is changed from single-bronchodilator therapy to dual-bronchodilator therapy. In addition, the quick bronchodilation effect and once-daily administration can improve patient adherence to medical treatment for chronic obstructive pulmonary disease (COPD). To our knowledge, as of November 2014, the safety and the efficacy of QVA149 have been evaluated in 14 randomized controlled trials. The 14 trials generally showed good safety profiles, and there were better or not-inferior bronchodilator effects of QVA149 when compared with placebo, or other inhaled medication. According to the Japanese Respiratory Society guidelines, QVA149 is a combination of the two first-line bronchodilators. Our meta-analysis indicated that QVA149 is superior to the salmeterol-fluticasone combination to treat COPD in respect of the frequency of adverse effects, exacerbation, pneumonia, and improvement of trough forced expiratory volume in 1 second (FEV1). Thus, we believe that QVA149 can be a key medication for COPD treatments.
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Affiliation(s)
- Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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37
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Babu KS, Kastelik JA, Morjaria JB. Inhaled corticosteroids in chronic obstructive pulmonary disease: a pro-con perspective. Br J Clin Pharmacol 2015; 78:282-300. [PMID: 25099256 DOI: 10.1111/bcp.12334] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 01/20/2014] [Indexed: 12/31/2022] Open
Abstract
Current guidelines limit regular use of inhaled corticosteroids (ICS) to a specific subgroup of patients with chronic obstructive pulmonary disease (COPD) in whom the forced expiratory volume in 1 s is <60% of predicted and who have frequent exacerbations. In these patients, there is evidence that ICS reduce the frequency of exacerbations and improve lung function and quality of life. However, a review of the literature suggests that the evidence available may be interpreted to favour or contradict these observations. It becomes apparent that COPD is a heterogeneous condition. Clinicians therefore need to be aware of the heterogeneity as well as having an understanding of how ICS may be used in the context of the specific subgroups of patients with COPD. This review argues for and against the use of ICS in COPD by providing an in-depth analysis of the currently available evidence.
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Affiliation(s)
- K Suresh Babu
- Department of Respiratory Medicine, Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire, UK
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D'Urzo A, Donohue JF, Kardos P, Miravitlles M, Price D. A re-evaluation of the role of inhaled corticosteroids in the management of patients with chronic obstructive pulmonary disease. Expert Opin Pharmacother 2015; 16:1845-60. [PMID: 26194213 PMCID: PMC4673525 DOI: 10.1517/14656566.2015.1067682] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) (in fixed combinations with long-acting β2-agonists [LABAs]) are frequently prescribed for patients with chronic obstructive pulmonary disease (COPD), outside their labeled indications and recommended treatment strategies and guidelines, despite having the potential to cause significant side effects. AREAS COVERED Although the existence of asthma in patients with asthma-COPD overlap syndrome (ACOS) clearly supports the use of anti-inflammatory treatment (typically an ICS/LABA combination, as ICS monotherapy is usually not indicated for COPD), the current level of ICS/LABA use is not consistent with the prevalence of ACOS in the COPD population. Data have recently become available showing the comparative efficacy of fixed bronchodilator combinations (long-acting muscarinic antagonist [LAMA]/LABA with ICS/LABA combinations). Additionally, new information has emerged on ICS withdrawal without increased risk of exacerbations, under cover of effective bronchodilation. EXPERT OPINION For patients with COPD who do not have ACOS, a LAMA/LABA combination may be an appropriate starting therapy, apart from those with mild disease who can be managed with a single long-acting bronchodilator. Patients who remain symptomatic or present with exacerbations despite effectively delivered LAMA/LABA treatment may require additional drug therapy, such as ICS or phosphodiesterase-4 inhibitors. When prescribing an ICS/LABA, the risk:benefit ratio should be considered in individual patients.
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Affiliation(s)
- Anthony D'Urzo
- University of Toronto, Department of Family and Community Medicine , 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7 , Canada +1 416 652 9336 ; +1 416 652 0218 ;
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Ernst P, Saad N, Suissa S. Inhaled corticosteroids in COPD: the clinical evidence. Eur Respir J 2014; 45:525-37. [PMID: 25537556 DOI: 10.1183/09031936.00128914] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this article, we focus on the scientific evidence from randomised trials supporting treatment with inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD), including treatment with combinations of long-acting β-agonist (LABA) bronchodilators and ICS. Our emphasis is on the methodological strengths and limitations that guide the conclusions that may be drawn. The evidence of benefit of ICS and, therefore, of the LABA/ICS combinations in COPD is limited by major methodological problems. From the data reviewed herein, we conclude that there is no survival benefit independent of the effect of long-acting bronchodilation and no effect on FEV1 decline, and that the possible benefit on reducing severe exacerbations is unclear. Our interpretation of the data is that there are substantial adverse effects from the use of ICS in patients with COPD, most notably severe pneumonia resulting in excess deaths. Currently, the most reliable predictor of response to ICS in COPD is the presence of eosinophilic inflammation in the sputum. There is an urgent need for better markers of benefit and risk that can be tested in randomised trials for use in routine specialist practice. Given the overall safety and effectiveness of long-acting bronchodilators in subjects without an asthma component to their COPD, we believe use of such agents without an associated ICS should be favoured.
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Affiliation(s)
- Pierre Ernst
- Dept of Medicine, Pulmonary Division, Jewish General Hospital, Montreal, Canada Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, Canada
| | - Nathalie Saad
- Dept of Medicine, Pulmonary Division, Jewish General Hospital, Montreal, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, Canada Dept of Epidemiology and Biostatistics, McGill University, Montréal, Canada
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Zafar MA, Droege C, Foertsch M, Panos RJ. Update on ultra-long-acting β agonists in chronic obstructive pulmonary disease. Expert Opin Investig Drugs 2014; 23:1687-701. [PMID: 25139313 DOI: 10.1517/13543784.2014.942730] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION For the last two decades, long-acting β agonists (LABAs) have been a cornerstone in the management of chronic obstructive pulmonary disease (COPD). They relax airway smooth muscle and augment expiratory airflow, which reduces hyperinflation and improves dyspnea, functional capacity and quality of life. In recent years, Indacaterol, a LABA with an ultra-long duration of action (ultra-LABA), which only requires once-daily dosing, was approved by the FDA. The clinical efficacy of indacaterol is comparable, and, in some aspects better, than the currently available LABAs. AREAS COVERED This article reviews the pharmacological properties, clinical efficacy, safety and potential role of the ultra-LABAs in COPD management. EXPERT OPINION Ultra-LABAs are effective bronchodilators with a prolonged duration of action. By decreasing dosing frequency, ultra-LABAs potentially may improve respiratory medication adherence, which is associated with better survival and less healthcare utilization. In addition to their salubrious benefits, β agonists may produce untoward effects. Increased mortality and hospitalizations among patients with left ventricular heart failure, who were treated with β agonists, has caused concern about their use in patients with COPD and heart disease. Further experience and testing will determine the optimal role of ultra-LABAs in the management of COPD.
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Affiliation(s)
- Muhammad Ahsan Zafar
- University of Cincinnati Medical Center, Division of Pulmonary and Critical Care Medicine , 1 Albert Sabin Way, MSB Room 6053, Mail Location 0564, Cincinnati, OH 45267 , USA
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41
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Gøtzsche PC. Questionable research and marketing of a combination drug for smoker's lungs. J R Soc Med 2014; 107:256-257. [PMID: 25013093 DOI: 10.1177/0141076814541847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Rho J, Ho N, Prasad V. Counterpoint: were industry-sponsored roflumilast trials appropriate? No. Chest 2014; 145:939-42. [PMID: 24798831 DOI: 10.1378/chest.14-0114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Kelly E. Umeclidinium bromide and vilanterol in combination for the treatment of chronic obstructive pulmonary disease. Expert Rev Clin Pharmacol 2014; 7:403-13. [PMID: 24909949 DOI: 10.1586/17512433.2014.926812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Drugs from the two major classes of bronchodilator; umeclidinium, a long-acting muscarinic antagonist (LAMA), and vilanterol, a long-acting β2 agonist (LABA), have been combined in a single inhaler device for once-daily use in chronic obstructive pulmonary disease (COPD). These drugs have been proven safe and well tolerated in patients with COPD and show an enhanced improvement in FEV1 when compared to either drug in isolation and when compared with an established LAMA drug. In this article, we discuss the data supporting this combination inhaler and also review alternative combined LAMA/LABA options. We discuss where these agents are likely to find a place in the current therapy of COPD and where the future is likely to lead with these and other therapies.
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Affiliation(s)
- Emer Kelly
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin 4, Ireland
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44
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Dual bronchodilation for the treatment of chronic obstructive pulmonary disease: a review of the latest clinical data. ACTA ACUST UNITED AC 2014. [DOI: 10.4155/cli.14.50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bateman ED, Mahler DA, Vogelmeier CF, Wedzicha JA, Patalano F, Banerji D. Recent advances in COPD disease management with fixed-dose long-acting combination therapies. Expert Rev Respir Med 2014; 8:357-79. [PMID: 24802656 DOI: 10.1586/17476348.2014.910457] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Combinations of two long-acting bronchodilators and long-acting bronchodilators with inhaled corticosteroids (ICS) are recommended therapies in the management of chronic obstructive pulmonary disease (COPD). Three fixed-dose combination products have recently been approved for the treatment of COPD (the long-acting β2-agonist plus long-acting muscarinic antagonist [LABA/LAMA] combinations glycopyrronium/indacaterol [QVA149] and umeclidinium/vilanterol, and the LABA/ICS fluticasone furoate/vilanterol), with others currently in late-stage development. LABA/LAMA and LABA/ICS combination therapies demonstrate positive effects on both lung function and patient-reported outcomes, with significant improvements observed with LABA/LAMA combinations compared with placebo, each component alone and other comparators in current use. No new safety concerns have been observed with combinations of long-acting bronchodilators. Combinations of two long-acting bronchodilators represent a new and convenient treatment option in COPD. This review summarizes published efficacy and safety data from clinical trials of both LABA/LAMA and novel LABA/ICS combinations in patients with COPD.
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Affiliation(s)
- Eric D Bateman
- Department of Medicine, Division of Pulmonology, University of Cape Town, George Street, Mowbray 7700, Cape Town, South Africa
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Suissa S, Rabe KF. Point: Were Industry-Sponsored Roflumilast Trials Appropriate? Yes. Chest 2014; 145:937-9. [DOI: 10.1378/chest.14-0112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Suissa S, Rabe KF. Rebuttal From Drs Suissa and Rabe. Chest 2014; 145:942-3. [DOI: 10.1378/chest.14-0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Morjaria JB, Morice AH. Fluticasone furoate and vilanterol for COPD. THE LANCET RESPIRATORY MEDICINE 2014; 1:e21. [PMID: 24429208 DOI: 10.1016/s2213-2600(13)70100-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jaymin B Morjaria
- Department of Academic Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, HU16 5JQ, UK.
| | - Alyn H Morice
- Department of Academic Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
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