1
|
Georgiou A, Ramesh R, Schofield P, White P, Harries TH. Withdrawal of Inhaled Corticosteroids from Patients with COPD; Effect on Exacerbation Frequency and Lung Function: A Systematic Review. Int J Chron Obstruct Pulmon Dis 2024; 19:1403-1419. [PMID: 38919905 PMCID: PMC11198025 DOI: 10.2147/copd.s436525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 06/01/2024] [Indexed: 06/27/2024] Open
Abstract
Background Inhaled corticosteroid (ICS) therapy has been demonstrated to reduce the risk of COPD exacerbations. It should only be prescribed to COPD patients who are not adequately controlled by dual long-acting bronchodilator therapy and who have ≥2 exacerbations per year and a blood eosinophil count ≥300cells/µL. ICS therapy is widely prescribed outside guidelines to COPD patients, making ICS withdrawal an important consideration. This systematic review aims to provide an up-to-date analysis of the effect of ICS withdrawal on exacerbation frequency, change in lung function (FEV1) and to determine the proportion of COPD patients who resume ICS therapy following withdrawal. Methods Randomised controlled trials (RCTs) and observational studies which compared ICS withdrawal with ICS continuation treatment were included. Cochrane Central, Web of Science, CINHAL, Embase and OVID Medline were searched. Risk of bias was assessed using the Cochrane RoB2 tool and the Newcastle-Ottawa Scale. Quality assessment of RCTs was conducted using GRADE. Meta-analysis of post-hoc analyses of RCTs of ICS withdrawal, stratified by blood eosinophil count (BEC), was undertaken. Results Ten RCTs (6642 patients randomised) and 6 observational studies (160,029 patients) were included in the results. When ICS was withdrawn and long-acting bronchodilator therapy was maintained, there was no consistent difference in exacerbation frequency or lung function change between the ICS withdrawal and continuation trial arms. The evidence for these effects was of moderate quality. There was insufficient evidence to draw a firm conclusion on the proportion of patients who resumed ICS therapy following withdrawal (estimated range 12-93% of the participants). Discussion Withdrawal of ICS therapy from patients with COPD is safe and feasible but should be accompanied by maintenance of bronchodilation therapy for optimal outcomes.
Collapse
Affiliation(s)
- Andrea Georgiou
- School of Population Health & Environmental Sciences, King’s College London, London, UK
| | - Reshma Ramesh
- School of Population Health & Environmental Sciences, King’s College London, London, UK
| | - Peter Schofield
- School of Population Health & Environmental Sciences, King’s College London, London, UK
| | - Patrick White
- School of Population Health & Environmental Sciences, King’s College London, London, UK
| | - Timothy H Harries
- School of Population Health & Environmental Sciences, King’s College London, London, UK
| |
Collapse
|
2
|
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.
Collapse
Affiliation(s)
| | - D Kyle Hogarth
- Pulmonary and Critical Care Medicine, The University of Chicago Medicine, Chicago, IL, USA
| |
Collapse
|
3
|
Khartabil N. Geriatric Pharmacotherapy Case Series: Chronic Obstructive Pulmonary Disease. Sr Care Pharm 2023; 38:465-471. [PMID: 37885095 DOI: 10.4140/tcp.n.2023.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Patient is a 77-year-old female who is a retired teacher living with her husband. Patient presents to the clinic for a post-hospital discharge visit. She was treated for bacterial pneumonia with combination therapy of azithromycin and cefpodoxime. She was diagnosed with COPD seven years ago when she had to be treated for chronic dyspnea, cough, and sputum that kept her breathless and required hospitalization.
Collapse
Affiliation(s)
- Nadia Khartabil
- West Coast University, School of Pharmacy, Los Angeles, California
| |
Collapse
|
4
|
Gong Y, Sui Z, Lv Y, Zheng Q, Li L. LABA/LAMA versus LABA/ICS fixed-dose combinations in the prevention of COPD exacerbations: a modeling analysis of literature aggregate data. Eur J Clin Pharmacol 2023; 79:1321-1332. [PMID: 37507595 DOI: 10.1007/s00228-023-03543-y] [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: 04/04/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVES This study aimed to quantitatively compare the efficacy and safety of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) and LABA/inhaled corticosteroid (ICS) fixed-dose combinations (FDCs) in preventing moderate or severe chronic obstructive pulmonary disease (COPD) exacerbations. METHODS A literature search was performed using public databases. The time course characteristics of the probability of a moderate or severe exacerbation in stable COPD patients treated with LABA/LAMA and LABA/ICS FDCs were described by the parametric survival function. A random-effects model in a single-arm meta-analysis was used to analyze the incidence of serious adverse events (SAEs) and pneumonia. RESULTS Twenty studies including 23,955 participants were included. The proportion of participants with a history of COPD exacerbation (%) in the previous year and the postbronchodilator forced expiratory volume in the first second (FEV1) (%predicted) were important factors affecting drug efficacy. After adjusting the above factors to median levels of 100% and 45.5%, respectively, the moderate or severe exacerbation rates at 52 weeks for olodaterol/tiotropium, formoterol/budesonide, indacaterol/glycopyrronium, formoterol/glycopyrronium, vilanterol/fluticasone, salmeterol/fluticasone, and vilanterol/umeclidinium were 38.3%, 41.0%, 42.6%, 47.0%, 47.5%, 47.9%, and 53.0%, respectively. In terms of safety, significant differences were observed among drugs containing different LABA/LAMA FDCs. CONCLUSIONS This study showed that not all LABA/LAMA FDCs were superior to LABA/ICS FDCs in safety and in preventing moderate or severe exacerbations in patients with stable COPD, providing important quantitative information for COPD-related guidelines.
Collapse
Affiliation(s)
- Yiwen Gong
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Zichao Sui
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Yinghua Lv
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Qingshan Zheng
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China
| | - Lujin Li
- Center for Drug Clinical Evaluation Shanghai, University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, China.
| |
Collapse
|
5
|
Nourian YH, Salimian J, Ahmadi A, Salehi Z, Karimi M, Emamvirdizadeh A, Azimzadeh Jamalkandi S, Ghanei M. cAMP-PDE signaling in COPD: Review of cellular, molecular and clinical features. Biochem Biophys Rep 2023; 34:101438. [PMID: 36865738 PMCID: PMC9971187 DOI: 10.1016/j.bbrep.2023.101438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/21/2023] [Accepted: 02/02/2023] [Indexed: 02/18/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death among non-contagious diseases in the world. PDE inhibitors are among current medicines prescribed for COPD treatment of which, PDE-4 family is the predominant PDE isoform involved in hydrolyzing cyclic adenosine monophosphate (cAMP) that regulates the inflammatory responses in neutrophils, lymphocytes, macrophages and epithelial cells The aim of this study is to investigate the cellular and molecular mechanisms of cAMP-PDE signaling, as an important pathway in the treatment management of patients with COPD. In this review, a comprehensive literature review was performed about the effect of PDEs in COPD. Generally, PDEs are overexpressed in COPD patients, resulting in cAMP inactivation and decreased cAMP hydrolysis from AMP. At normal amounts, cAMP is one of the essential agents in regulating metabolism and suppressing inflammatory responses. Low amount of cAMP lead to activation of downstream inflammatory signaling pathways. PDE4 and PDE7 mRNA transcript levels were not altered in polymorphonuclear leukocytes and CD8 lymphocytes originating from the peripheral venous blood of stable COPD subjects compared to healthy controls. Therefore, cAMP-PDE signaling pathway is one of the most important signaling pathways involved in COPD. By examining the effects of different drugs in this signaling pathway critical steps can be taken in the treatment of this disease.
Collapse
Affiliation(s)
- Yazdan Hasani Nourian
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Jafar Salimian
- Applied Virology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ali Ahmadi
- Molecular Biology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Zahra Salehi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Karimi
- Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Emamvirdizadeh
- Department of Molecular Genetics, Faculty of Bio Sciences, Tehran North Branch, Islamic Azad University, Tehran, Iran
| | - Sadegh Azimzadeh Jamalkandi
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran,Corresponding author.
| | - Mostafa Ghanei
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| |
Collapse
|
6
|
Chen H, Deng ZX, Sun J, Huang Q, Huang L, He YH, Ma C, Wang K. Association of Inhaled Corticosteroids With All-Cause Mortality Risk in Patients With COPD: A Meta-analysis of 60 Randomized Controlled Trials. Chest 2023; 163:100-114. [PMID: 35921883 DOI: 10.1016/j.chest.2022.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/04/2022] [Accepted: 07/17/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICSs) have been used widely in the maintenance therapy of COPD. However, whether inhaled therapy containing ICSs can reduce the all-cause mortality risk and the possible benefited patient subgroups is unclear. RESEARCH QUESTION Does inhaled therapy containing ICSs reduce the all-cause mortality risk in patients with COPD compared with other inhaled therapies not containing ICSs? STUDY DESIGN AND METHODS We searched PubMed, Cochrane Library, Embase, and ClinicalTrials.gov for relevant randomized clinical trials (RCTs). Pooled results were calculated using Peto ORs with corresponding 95% CIs. RESULTS Sixty RCTs enrolling 103,034 patients were analyzed. Inhaled therapy containing ICSs (Peto OR, 0.90; 95% CI, 0.84-0.97), especially triple therapy (Peto OR, 0.73; 95% CI, 0.59-0.91), was associated with a reduction in the all-cause mortality risk among patients with COPD when compared with inhaled therapy without ICSs. Subgroup analyses revealed that treatment duration of > 6 months (Peto OR, 0.90; 95% CI, 0.83-0.97), medium-dose ICSs (Peto OR, 0.71; 95% CI, 0.56-0.91), low-dose ICSs (Peto OR, 0.88; 95% CI, 0.79-0.97), and budesonide (Peto OR, 0.75; 95% CI, 0.59-0.94) were involved in this association. The predictors of this association included eosinophil counts of ≥ 200/μL or percentage of ≥ 2%, documented history of ≥ 2 moderate and severe exacerbations in the previous year, Global Initiative for Chronic Obstructive Lung Disease stages III or IV, age younger than 65 years, and BMI of ≥ 25 kg/m2, among which eosinophil counts of ≥ 200/μL (Peto OR, 0.58; 95% CI, 0.36-0.95) were the strongest predictor. INTERPRETATION Inhaled therapy containing ICSs, especially triple therapy, of longer than 6 months was associated with a reduction in the all-cause mortality risk in patients with COPD. The predictors of this association included medication factors and patient characteristics, among which eosinophil counts of ≥ 200/μL were the strongest predictor. TRIAL REGISTRY PROSPERO; No.: CRD42022304725; URL: https://www.crd.york.ac.uk/prospero/.
Collapse
Affiliation(s)
- Hong Chen
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Zheng-Xu Deng
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Jian Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Qiang Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Lan Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Yong-Hong He
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Chunlan Ma
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
7
|
Neches García V, Vallejo-Aparicio LA, Ismaila AS, Sicras-Mainar A, Sicras-Navarro A, González C, Cuervo R, Shukla S, García-Peñuela M. Clinical and Economic Impact of Long-Term Inhaled Corticosteroid Withdrawal in Patients with Chronic Obstructive Pulmonary Disease Treated with Triple Therapy in Spain. Int J Chron Obstruct Pulmon Dis 2022; 17:2161-2174. [PMID: 36101793 PMCID: PMC9464437 DOI: 10.2147/copd.s367708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the clinical and economic impact of inhaled corticosteroid (ICS) withdrawal in Spanish patients with COPD receiving triple therapy (TT) with ICS, long-acting β2-agonist (LABA), and long-acting muscarinic antagonist (LAMA). Patients and Methods This was an observational, retrospective study of BIG-PAC database medical records. Patients aged ≥40 years receiving TT from 2016 to 2018 were followed for 1 year. Two cohorts were identified: patients continuing TT (ICS+LABA+LAMA), and patients receiving TT with ICS withdrawn (LABA+LAMA). Variables included medication, exacerbations (moderate and severe), pneumonia, mortality, health resource use (HRU), and cost per patient/year. Cohorts were compared using propensity score matching (PSM). Multivariate statistical analysis using analysis of covariance and Cox proportional risks was conducted. Results Of 6541 patients included, 5740 (87.8%) continued TT and 801 (12.2%) had ICS withdrawn. Patients with ICS withdrawal were younger, had lower disease burden, higher ICS doses, and more exacerbations compared with those continuing ICS. PSM matched 795 patients in each cohort. Mean age was 68.5 years (SD: 11.2), 69.9% were male, and mean Charlson index was 2.0. Patients with ICS withdrawal had more total exacerbations in the 12 months following withdrawal compared with patients continuing TT (36.6% vs 31.4%; p=0.030). No significant differences were found for pneumonia (3.3% vs 3.6%; p=0.583) and mortality (9.9% vs 7.5%; p=0.092). Median time to first exacerbation was shorter in patients with ICS withdrawal compared with those continuing ICS (HR: 0.69, 95% CI: 0.57–0.83; p<0.001). Mean health cost per patient/year among patients with ICS withdrawal was higher than those continuing TT (€2993 vs €2130; p<0.001). Conclusion ICS withdrawal in patients with COPD receiving TT was associated with increased exacerbations, HRU, and costs compared with continuing TT, with health and economic impacts on patients and the Spanish National Healthcare System, respectively. Pneumonia and mortality rates were similar between groups.
Collapse
Affiliation(s)
| | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | | | - Cruz González
- Pneumology Unit, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Soham Shukla
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA
| | | |
Collapse
|
8
|
Miravitlles M, González-Torralba F, Represas-Represas C, Pomares X, Márquez-Martín E, González C, Amado C, Forné C, Alonso S, Alcázar B, Barrecheguren M, Jurado Mirete JM, Naval E. Pulmonologists' Opinion on the Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Patients in Spain: A Cross-Sectional Survey. Int J Chron Obstruct Pulmon Dis 2022; 17:1577-1587. [PMID: 35855745 PMCID: PMC9288191 DOI: 10.2147/copd.s369118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD. Methods A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal. Results A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction. Conclusion In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice.
Collapse
Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain
| | | | | | - Xavier Pomares
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Pneumology Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Eduardo Márquez-Martín
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Medical-Surgical Unit for Respiratory Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Cruz González
- Pneumology Department, Hospital Clínico de Valencia, Valencia, Spain
| | - Carlos Amado
- Pneumology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carles Forné
- Heorfy Consulting, Lleida, Spain.,Basic Medical Sciences Department, University of Lleida, Lleida, Spain
| | - Soledad Alonso
- Pneumology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Bernardino Alcázar
- Pneumology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Elsa Naval
- Pneumology Department, Hospital Universitario de La Ribera, Alzira, Spain
| |
Collapse
|
9
|
Ding Y, Sun L, Wang Y, Zhang J, Chen Y. Efficacy of ICS versus Non-ICS Combination Therapy in COPD: A Meta-Analysis of Randomised Controlled Trials. Int J Chron Obstruct Pulmon Dis 2022; 17:1051-1067. [PMID: 35547781 PMCID: PMC9084385 DOI: 10.2147/copd.s347588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/24/2022] [Indexed: 12/15/2022] Open
Abstract
Background Methods Results Conclusion
Collapse
Affiliation(s)
- Yanling Ding
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Lina Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Ying Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
- Correspondence: Jing Zhang; Yahong Chen, Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China, Tel +86 13-8104-57631, Email ;
| | - Yahong Chen
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| |
Collapse
|
10
|
Suissa S, Dell'Aniello S, Ernst P. Discontinuation of Inhaled Corticosteroids from Triple Therapy in COPD: Effects on Major Outcomes in Real World Clinical Practice. COPD 2022; 19:133-141. [PMID: 35392746 DOI: 10.1080/15412555.2022.2045265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Recent reports provide evidence-based guidelines for the withdrawal of inhaled corticosteroids (ICS) in COPD, but data on patients treated with ICS-based triple therapy are sparse and contradictory. We assessed the effect of ICS discontinuation on the incidence of severe exacerbation and pneumonia in a real-world population of patients with COPD who initiated triple therapy. We identified a cohort of patients with COPD treated with LAMA-LABA-ICS triple therapy during 2002-2018, age 50 or older, from the UK's CPRD database. Subjects who discontinued ICS were matched 1:1 on time-conditional propensity scores to those continuing ICS and followed for one year. Hazard ratios (HR) of severe exacerbation and pneumonia were estimated using Cox regression. The cohort included 42,667 patients who discontinued ICS matched to 42,667 who continued ICS treatment. The hazard ratio of a severe exacerbation with ICS discontinuation relative to ICS continuation was 0.86 (95% CI: 0.78-0.95), while for severe pneumonia it was 0.96 (95% CI: 0.88-1.05). The incidence of severe exacerbation after ICS discontinuation was numerically higher than after continuation among patients with two or more exacerbations in the prior year (HR 1.09; 95% CI: 0.94-1.26) and among those with FEV1 <30% predicted (HR 1.29; 95% CI: 1.04-1.59). This large real-world study in the clinical setting of COPD treatment suggests that certain patients on triple therapy can be safely withdrawn from ICS and remain on bronchodilator therapy. As residual confounding cannot be ruled out, ICS discontinuation is not warranted for patients with multiple exacerbations and with very severe airway obstruction.
Collapse
Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada.,Departments of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Québec, Canada
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada.,Departments of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Québec, Canada
| |
Collapse
|
11
|
Valipour A, Aisanov Z, Avdeev S, Koblizek V, Kocan I, Kopitovic I, Lupkovics G, Man M, Bukovskis M, Tudoric N, Vukoja M, Naumnik W, Yanev N. Recommendations for COPD management in Central and Eastern Europe. Expert Rev Respir Med 2022; 16:221-234. [PMID: 35001780 DOI: 10.1080/17476348.2021.2023498] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries. AREAS COVERED Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE. EXPERT OPINION Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.
Collapse
Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna Health Care Group, Vienna, Austria
| | - Zaurbek Aisanov
- Department of Pulmonology, Pirogov Russian State National Research Medical University, Moscow, Russia
| | - Sergey Avdeev
- Pulmonology Department, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vladimir Koblizek
- Department of Pneumology, Faculty of Medicine in Hradec Kralove, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Ivan Kocan
- University Hospital Martin, Jessenius Faculty of Medicine, Commenius University, Martin, Slovakia
| | - Ivan Kopitovic
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Gergely Lupkovics
- Adult Pulmonary Department, Institute for Pulmonary Diseases, Törökbálint, Hungary
| | - Milena Man
- Pulmonology Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maris Bukovskis
- Department of Internal Diseases, Faculty Medicine, University of Latvia, Riga, Latvia
| | - Neven Tudoric
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marija Vukoja
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Wojciech Naumnik
- First Department of Lung Diseases and Chemotherapy of Respiratory Neoplasms, Medical University of Bialystok, Bialystok, Poland
| | - Nikolay Yanev
- Department of Pulmonary Diseases, Medical University of Sofia, Sofia, Bulgaria
| |
Collapse
|
12
|
Wise RA, Bafadhel M, Crim C, Criner GJ, Day NC, Halpin DMG, Han MK, Lange P, Lipson DA, Martinez FJ, Maselli DJ, Midwinter D, Singh D, Zysman M, Dransfield MT, Russell REK. Discordant diagnostic criteria for pneumonia in COPD trials: a review. Eur Respir Rev 2021; 30:30/162/210124. [PMID: 34789465 PMCID: PMC9488621 DOI: 10.1183/16000617.0124-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/28/2021] [Indexed: 01/21/2023] Open
Abstract
Inhaled corticosteroids (ICS) have a class effect of increasing pneumonia risk in patients with COPD. However, pneumonia incidence varies widely across clinical trials of ICS use in COPD. This review clarifies methodological differences in defining and recording pneumonia events in these trials and discusses factors that could contribute to the varying pneumonia incidence. Literature searches and screening yielded 40 relevant references for inclusion. Methods used to capture pneumonia events in these studies included investigator-reported pneumonia adverse events, standardised list of signs or symptoms, radiographic confirmation of suspected cases and/or confirmation by an independent clinical end-point committee. In general, more stringent pneumonia diagnosis criteria led to lower reported pneumonia incidence rates. In addition, studies varied in design and population characteristics, including exacerbation history and lung function, factors that probably contribute to the varying pneumonia incidence. As such, cross-trial comparisons are problematic. A minimal set of standardised criteria for diagnosis and reporting of pneumonia should be used in COPD studies, as well as reporting of patients’ pneumonia history at baseline, to allow comparison of pneumonia rates between trials. Currently, within-trial comparison of ICS-containing versus non-ICS-containing treatments is the appropriate method to assess the influence of ICS on pneumonia incidence. Trials of ICS in COPD use varying methods of reporting pneumonia incidence, which influence the interpretation of results. A minimal set of standardised criteria for pneumonia diagnosis would allow comparison of pneumonia incidence between trials.https://bit.ly/3nbkdoL
Collapse
Affiliation(s)
- Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mona Bafadhel
- Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Courtney Crim
- Clinical Sciences - Respiratory, GSK, Research Triangle Park, NC, USA.,Affiliation at the time of writing
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - MeiLan K Han
- University of Michigan, Pulmonary & Critical Care, Ann Arbor, MI, USA
| | - Peter Lange
- Section of Epidemiology, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical Dept, Herlev and Gentofte Hospital, Herlev, Denmark
| | - David A Lipson
- Clinical Sciences, GSK, Collegeville, PA, USA.,Pulmonary, Allergy and Critical Care Division, Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando J Martinez
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Diego J Maselli
- Dept of Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
| | | | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Foundation Hospital Trust, Manchester, UK
| | - Maeva Zysman
- Service des Maladies Respiratoires, CHU Bordeaux, Pessac, France.,Univ-Bordeaux, Centre de Recherche cardio-thoracique de Bordeaux, U1045, CIC 1401, Pessac, France
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | | |
Collapse
|
13
|
Abstract
Recent trials reported significant reductions in all-cause mortality with single-inhaler triple therapy for chronic obstructive pulmonary disease (COPD). However, reviews of these trials identified inconsistencies in the findings and methodological issues with the design and analysis, including the "adverse impact of inhaled corticosteroid (ICS) withdrawal rather than the addition" of the triple therapy. Indeed, ICS were discontinued in over 70% of the patients in these trials and 40% already using triple therapy, muddying the interpretation of the data. The "adaptive" clinical trial design is an efficient approach that allows continual modification of the study treatment allocation during follow-up. In this article, we propose the "adaptive selection" trial design, which applies the adaptive concept to the selection of patients into the trial by adapting the randomization choices to the treatment already used by the patients. With such a design, patients already on triple therapy would be excluded outright from trials of triple therapy effectiveness, while the others are randomly allocated to specific treatment arms according to their current treatment, avoiding issues of treatment withdrawal effects. Adaptive selection trials should be the norm for studies of COPD therapies. This approach would avoid the vexing effects of treatment withdrawal that have afflicted the recent triple therapy trials. This concept of adaptive selection has been applied in COPD to the question of whether patients can be safely de-escalated from ICS. It is time to also apply it to studies of the effectiveness of treatment escalation.
Collapse
Affiliation(s)
- Samy Suissa
- Departments of Epidemiology and Biostatistics and of Medicine, Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
14
|
Comorbid Anxiety and Depression, Though Underdiagnosed, Are Not Associated with High Rates of Low-Value Care in Patients with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 18:442-451. [PMID: 33306930 DOI: 10.1513/annalsats.201912-877oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with chronic obstructive pulmonary disease (COPD) and anxiety or depression experience more symptoms and exacerbations than patients without these comorbidities. Failure to provide beneficial COPD therapies to appropriate patients (underuse) and provision of potentially harmful therapies to patients without an appropriate indication (overuse) could contribute to respiratory symptoms and exacerbations. Anxiety and depression are known to affect the provision of health services for other comorbid conditions; therefore, underuse or overuse of therapies may explain the increased risk of severe symptoms among these patients.Objectives: To determine whether diagnosed anxiety and depression, as well as significant anxiety and depression symptoms, are associated with underuse and overuse of appropriate COPD therapies.Methods: We analyzed data from a multicenter prospective cohort study of 2,376 participants (smokers and control subjects) enrolled between 2010 and 2015. We identified two subgroups of participants, one at risk for inhaled corticosteroid (ICS) overuse and one at risk for long-acting bronchodilator (LABD) underuse based on the 2011 Global Initiative for Chronic Obstructive Lung Disease statement. Our primary outcomes were self-reported overuse and underuse. Our primary exposures of interest were self-reported anxiety and depression and significant anxiety and depression symptoms. We adopted a propensity-score method with inverse probability of treatment weighting adjusting for differences in prevalence of confounders and performed inverse probability of treatment weighting logistic regression to evaluate all associations between the exposures and outcomes.Results: Among the 1,783 study participants with COPD confirmed by spirometry, 667 (37.4%) did not have an indication for ICS use, whereas 985 (55.2%) had an indication for LABD use. Twenty-five percent (n = 167) of patients reported ICS use, and 72% (n = 709) denied LABD use in each subgroup, respectively. Neither self-reported anxiety and depression nor significant anxiety and depression symptoms were associated with overuse or underuse. At least 50% of patients in both subgroups with significant symptoms of anxiety or depression did not report a preexisting mental health diagnosis.Conclusions: Underuse of LABDs and overuse of ICSs are common but are not associated with comorbid anxiety or depression diagnosis or symptoms. Approximately one-third of individuals with COPD experience anxiety or depression, and most are undiagnosed. There are significant opportunities to improve disease-specific and patient-centered treatment for individuals with COPD.
Collapse
|
15
|
Chen H, Sun J, Huang Q, Liu Y, Yuan M, Ma C, Yan H. Inhaled Corticosteroids and the Pneumonia Risk in Patients With Chronic Obstructive Pulmonary Disease: A Meta-analysis of Randomized Controlled Trials. Front Pharmacol 2021; 12:691621. [PMID: 34267661 PMCID: PMC8275837 DOI: 10.3389/fphar.2021.691621] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Whether all types of inhaled corticosteroids (ICSs) would increase the pneumonia risk in patients with chronic obstructive pulmonary disease (COPD) remains controversial. We aimed to assess the association between ICSs treatment and pneumonia risk in COPD patients, and the impact of medication details and baseline characteristics of patients on the association. Methods: Four databases (PubMed, Embase, Cochrane Library, and Clinical Trials.gov) were searched to identify eligible randomized controlled trials (RCTs) comparing ICSs treatment with non-ICSs treatment on the pneumonia risk in COPD patients. Pooled results were calculated using Peto odds ratios (Peto ORs) with corresponding 95% confidence intervals (CIs). Results: A total of 59 RCTs enrolling 103,477 patients were analyzed. All types of ICSs significantly increased the pneumonia risk (Peto OR, 1.43; 95% CI, 1.34–1.53). Subgroup analysis showed that there was a dose-response relationship between ICSs treatment and pneumonia risk (low-dose: Peto OR, 1.33; 95% CI, 1.22–1.45; medium-dose: Peto OR, 1.50; 95% CI, 1.28–1.76; and high-dose: Peto OR, 1.64; 95% CI, 1.45–1.85). Subgroup analyses based on treatment durations and baseline characteristics (severity, age, and body mass index) of patients were consistant with the above results. Subgroup analysis based on severity of pneumonia showed that fluticasone (Peto OR, 1.75; 95% CI, 1.44–2.14) increased the risk of serious pneumonia, while budesonide and beclomethasone did not. Conclusions: ICSs treatment significantly increased the risk of pneumonia in COPD patients. There was a dose-response relationship between ICSs treatment and pneumonia risk. The pneumonia risk was related with COPD severity.
Collapse
Affiliation(s)
- Hong Chen
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Jian Sun
- Department of Respiratory, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Qiang Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Yongqi Liu
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Mengxin Yuan
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Chunlan Ma
- Department of Respiratory, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Hao Yan
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| |
Collapse
|
16
|
Tsiligianni I, Hoeines KJ, Jensen C, Kocks JWH, Ställberg B, Vicente C, Peché R. Towards Rational Prescription of Common Inhaler Medication in the Multimorbid COPD Patient. Int J Chron Obstruct Pulmon Dis 2021; 16:1315-1327. [PMID: 34012259 PMCID: PMC8127323 DOI: 10.2147/copd.s298345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/31/2021] [Indexed: 11/23/2022] Open
Abstract
COPD is a chronic disease, typically accompanied by multiple comorbid conditions. The need to apply several, and sometimes conflicting, disease-specific treatment guidelines, complicates the management of individual patients. Moreover, national and international recommendations evolve rapidly but provide limited guidance on the integrated approach in the multimorbid patient. Particularly bothersome is the fact that the presence of comorbidities may deteriorate the course of COPD, and inversely COPD may affect the outcome of the comorbid diseases. In addition, some effects of commonly prescribed COPD inhaler medications, including beta2-agonists, long-acting antimuscarinics and especially inhaled corticosteroids, mimic or worsen COPD-related comorbidities. Therefore, the authors combined their perspectives to formulate advice that may help physicians to improve COPD patient care in daily practice when comorbidities are present. Diabetes, atrial fibrillation, osteoporosis/fractures, infections (pneumonia and tuberculosis) and asthma were identified as areas where practicing clinicians should give special attention to the risk-benefit ratio of the inhaled medication. Overall, the presence of multimorbidity in a COPD patient should act as a signal to carefully reconsider the treatment choices.
Collapse
Affiliation(s)
| | | | | | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Rudi Peché
- Department of Pneumology, ISPPC, CHU Charleroi, Charleroi, Belgium
| |
Collapse
|
17
|
Nielsen AO, Hilberg O, Jensen JUS, Kristensen SH, Frølund JC, Langkilde PK, Løkke A. Withdrawal of Inhaled Corticosteroids in Patients with COPD - A Prospective Observational Study. Int J Chron Obstruct Pulmon Dis 2021; 16:807-815. [PMID: 33814904 PMCID: PMC8009342 DOI: 10.2147/copd.s294217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) are widely used in the treatment of chronic obstructive pulmonary disease (COPD), but recent studies have raised doubts whether all COPD patients will benefit from ICS. This study evaluates in a real-life setting the effects of ICS withdrawal in patients with COPD. Methods The study was a prospective intervention study following patients with COPD for 6 months after abrupt withdrawal of ICS. FEV1 (L), blood eosinophilic count (x10E9/L) and number of exacerbations were measured at baseline, 1, 3 and 6 months after ICS withdrawal. Results Ninety-six patients (56 females (57.4%), mean age 70 years (51-94 years)) with COPD were included in the study. Eleven patients were excluded during the study period (7 patients died, 4 patients withdrew their consent during the study period). During the 6 months, 51 patients (60%) had resumed treatment with ICS, of whom 34 patients (68%) experienced an exacerbation during follow-up. No significant decline in FEV1 was seen in this group between baseline and after 6 months (ΔFEV1 0.07 L, p = 0.09). In the remaining 34 patients (40%) without ICS after 6 months of follow-up, 15 patients (44.1%) experienced an exacerbation. No significant decline was seen in FEV1 at baseline and after 6 months (ΔFEV1 0.04 L, p = 0.28). There were no statistically significant differences between the two groups in age (70.5 vs 69.6 years, p = 0.53), nor between FEV1 at baseline (0.96 L vs 1.00 L, p = 0.63) or eosinophilic count (0.25 x10E9/L vs 0.17 x10E9/L, p = 0.07). Conclusion Abrupt withdrawal of ICS was possible in some patients. However, more than half of the patients resumed ICS during follow-up. Based on results from our study we were not able to foresee - from neither history of exacerbations nor eosinophilic count - whom will be able to manage without ICS and who will resume treatment with ICS.
Collapse
Affiliation(s)
| | - Ole Hilberg
- Department of Medicine, Hospital Little Belt, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jens Ulrik Stæhr Jensen
- Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Anders Løkke
- Department of Medicine, Hospital Little Belt, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
18
|
Yawn BP, Mintz ML, Doherty DE. GOLD in Practice: Chronic Obstructive Pulmonary Disease Treatment and Management in the Primary Care Setting. Int J Chron Obstruct Pulmon Dis 2021; 16:289-299. [PMID: 33603355 PMCID: PMC7886101 DOI: 10.2147/copd.s222664] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Early detection and appropriate treatment and management of COPD can lower morbidity and perhaps mortality. Clinicians in the primary care setting provide the majority of COPD care and are pivotal in the diagnosis and management of COPD. In this review, we provide an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 report, with a focus on the management of COPD in the primary care setting. We discuss the pathophysiology of COPD; describe COPD risk factors, signs, and symptoms that may facilitate earlier diagnosis of COPD; and reinforce the importance of spirometry use in establishing the diagnosis of COPD. Disease monitoring, as well as a review of the 2020 GOLD treatment recommendations, is also discussed. Patients and families are important partners in COPD management; therefore, we outline simple steps that may assist them in caring for those affected by COPD. Finally, we discuss nonpharmacological treatment options for COPD, COPD monitoring tools that may aid in the evaluation of disease progression and response to therapy, and the importance of developing a COPD action plan on an individualized basis.
Collapse
Affiliation(s)
- Barbara P Yawn
- Department of Family and Community Health, University of Minnesota, Minneapolis, MN, USA.,COPD Foundation, Miami, FL, USA
| | - Matthew L Mintz
- Department of Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Dennis E Doherty
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
19
|
Wang CY, Lai CC. The Role of Eosinophils during the Withdrawal of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2021; 203:144-145. [PMID: 32986465 PMCID: PMC7781124 DOI: 10.1164/rccm.202008-3040le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
|
20
|
Suissa S. Inhaled Corticosteroid Withdrawal in Chronic Obstructive Pulmonary Disease: Can IMPACT Help? Am J Respir Crit Care Med 2020; 202:1202-1204. [PMID: 32758097 PMCID: PMC7605197 DOI: 10.1164/rccm.202006-2600ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology and Biostatistics and.,Department of Medicine, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
21
|
Calverley P. Angels Dancing on the Tip of a Needle: Interpreting Clinical Trials in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2020; 202:1206-1207. [PMID: 32758103 PMCID: PMC7605183 DOI: 10.1164/rccm.202007-2863ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
22
|
Pragmatic trial on inhaled corticosteroid withdrawal in patients with COPD in general practice. NPJ Prim Care Respir Med 2020; 30:43. [PMID: 33037200 PMCID: PMC7547069 DOI: 10.1038/s41533-020-00198-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 07/28/2020] [Indexed: 01/11/2023] Open
Abstract
The therapeutic value of inhaled corticosteroids (ICSs) for COPD is limited. In published RCTs, ICS could be withdrawn in COPD patients without increasing exacerbation risk when bronchodilator treatment is optimized. Here we report on the feasibility and risks of ICS withdrawal in Dutch general practice for COPD patients without an indication for ICSs. In our pragmatic trial, general practitioners decided autonomously which of their COPD patients on ICS treatment could stop this, how this was done, and whether additional bronchodilator therapy was needed. We recruited 62 COPD patients (58 analysed) who were eligible for ICS withdrawal in 79 practices. In 32 patients (55.2%, 95% CI: 42.5–67.3%) ICS was withdrawn successfully, 19 (32.8%, 95% CI: 22.1–45.6%) restarted ICS treatment within six months, 12 patients (20.7%, 95% CI: 12.3–32.8%) had a moderate exacerbation, and one patient had a severe exacerbation. ICS withdrawal was successful in just over half of the patients with COPD without an indication for ICS.
Collapse
|
23
|
Contoli M, Morandi L, Di Marco F, Carone M. A perspective for chronic obstructive pulmonary disease (COPD) management: six key clinical questions to improve disease treatment. Expert Opin Pharmacother 2020; 22:427-437. [PMID: 33021128 DOI: 10.1080/14656566.2020.1828352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In 2011, the GOLD recommendations for the treatment of Chronic Obstructive Pulmonary Disease (COPD) introduced new clinical elements to classify the severity of the disease and to guide pharmacological choice. For the first time in the GOLD documents, treatment decision was no longer guided only by pulmonary function, but by a more complex combination of pulmonary function and clinical aspects. The recent versions of the GOLD recommendations introduce new aspects for the clinicians and pose new question for the management of the disease. In addition, inflammatory biomarkers and blood eosinophil levels, have been considered to guide treatment selection. AREA COVERED The evolution of disease management proposed by the GOLD document opens several areas of debate. A series of roundtable discussions among respiratory physicians took place in Italy to address key clinical questions. Particularly, the role of lung function and the use of biomarkers, the adherence to international guidelines and the possibility to personalize the pharmacological approach in COPD patients have been discussed, summarized and analyzed. EXPERT OPINION The authors believe that the development of a precision medicine approach tailoring the specific treatment for each patient is the goal of COPD management and may be achieved by considering the phenotypic classification of COPD patients.
Collapse
Affiliation(s)
- Marco Contoli
- Department of Morphology, Surgery and Experimental Medicine, Università Di Ferrara, Ferrara, Italy
| | - Luca Morandi
- Department of Morphology, Surgery and Experimental Medicine, Università Di Ferrara, Ferrara, Italy
| | - Fabiano Di Marco
- Department of Health Science, Università degli studi di Milano, Respiratory Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mauro Carone
- Division of Pneumology, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| |
Collapse
|
24
|
Rogliani P, Ritondo BL, Gabriele M, Cazzola M, Calzetta L. Optimizing de-escalation of inhaled corticosteroids in COPD: a systematic review of real-world findings. Expert Rev Clin Pharmacol 2020; 13:977-990. [DOI: 10.1080/17512433.2020.1817739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Paola Rogliani
- Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | | | - Mariachiara Gabriele
- Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| |
Collapse
|
25
|
Reducing the use of inhaled corticosteroids in mild-moderate COPD: an observational study in east London. NPJ Prim Care Respir Med 2020; 30:34. [PMID: 32737296 PMCID: PMC7395712 DOI: 10.1038/s41533-020-00191-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 05/21/2020] [Indexed: 12/02/2022] Open
Abstract
Inhaled corticosteroids (ICS) are often prescribed for worsening breathlessness, exacerbation frequency or lung function in chronic obstructive pulmonary disease (COPD). In mild-moderate disease and infrequent exacerbations, treatment risks may outweigh benefits and ICS may be withdrawn safely under supervision. A systematic ICS deprescribing programme for patients with mild-moderate COPD was introduced in an east London Clinical Commissioning Group (CCG) in April 2017. Primary care patient record analysis found that prescribing fell from 34.9% (n = 701) in the 18 months pre-intervention to 26.9% (n = 538) by the second year of implementation, decreasing 0.84% per quarter post intervention (p = 0.006, linear regression). The relative decrease was greater than the comparison CCG (23.0% vs. 9.9%). Only South Asian ethnicity was associated with increased cessation (odds ratio 1.48, confidence interval (CI) 1.09–2.01), p = 0.013, logistic regression). Patient outcome data were not collected. A primary care-led programme comprising local education, financial incentivisation and consultant support led to a significant decrease in ICS prescribing.
Collapse
|
26
|
Zhang Q, Li S, Zhou W, Yang X, Li J, Cao J. Risk of Pneumonia with Different Inhaled Corticosteroids in COPD Patients: A Meta-Analysis. COPD 2020; 17:462-469. [PMID: 32643439 DOI: 10.1080/15412555.2020.1787369] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ICS are anti-inflammatory agents which have been suggested to benefit people with worsening symptoms of COPD, by improving lung function, reducing exacerbation of disease, and enhancing overall quality of life. This systematic review and meta-analysis explored the association of the risk of pneumonia in COPD patients that were undergoing treatment using ICS alone or together with LABAs or LAMAs. PubMed, Cochrane Library and EMBASE were systematically searched through August 1, 2019; only double-blinded randomized controlled trials were eligible for this study. Eighteen randomized controlled trials were included. ICS treatment was linked to increased pneumonia incidence (RR, 1.47; 95% CI, 1.26-1.71; p < 0.001; I2 = 39.6%). Patients treated with salmeterol/fluticasone were more likely to have experience pneumonia-related adverse events than those treated using budesonide/formoterol or beclomethasone/formoterol. In subgroup analyses, pneumonia risk was found to be higher in the subgroups: >65 years old, lowest baseline forced expiratory volume in the first second of expiration (FEV1) < 50% of the predicted value, highest ICS dose, and long duration of ICS use. Furthermore, we compared fluticasone propionate with fluticasone furoate and determined that pneumonia incidence was higher in the former group and pneumonia incidence rose as doses rose in these two groups. However, no difference was observed between the budesonide and beclomethasone groups. ICS treatment was linked to an elevated pneumonia risk, different kinds of ICS lead to different rates of pneumonia.
Collapse
Affiliation(s)
- Qian Zhang
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Shuo Li
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Zhou
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Xia Yang
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinna Li
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Jie Cao
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| |
Collapse
|
27
|
Chalmers JD, Laska IF, Franssen FME, Janssens W, Pavord I, Rigau D, McDonnell MJ, Roche N, Sin DD, Stolz D, Suissa S, Wedzicha J, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline. Eur Respir J 2020; 55:13993003.00351-2020. [PMID: 32366483 DOI: 10.1183/13993003.00351-2020] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 02/06/2023]
Abstract
Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question: should ICS be withdrawn in patients with COPD? The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendations formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, and feasibility and acceptability of interventions, the guideline panel made: 1) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations, 2) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ≥300 eosinophils·µL-1 and 3) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.A conditional recommendation indicates that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.
Collapse
Affiliation(s)
- James D Chalmers
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
| | - Irena F Laska
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,These three authors contributed equally to the development of this guideline
| | - Frits M E Franssen
- Dept of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Dept of Research and Education, CIRO, Horn, The Netherlands
| | - Wim Janssens
- Clinical Dept of Respiratory Diseases, UZ Leuven and Breathe, Dept CHROMETA, KU Leuven, Leuven, Belgium
| | - Ian Pavord
- Oxford NIHR Respiratory BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | | | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, AP-HP Centre University of Paris, Cochin Institute (UMR1016), Paris, France
| | - Don D Sin
- Centre for Heart Lung Innovation, St Paul's Hospital and Respiratory Division, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital and Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Jadwiga Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
| |
Collapse
|
28
|
Tashkin DP, Amin AN, Kerwin EM. Comparing Randomized Controlled Trials and Real-World Studies in Chronic Obstructive Pulmonary Disease Pharmacotherapy. Int J Chron Obstruct Pulmon Dis 2020; 15:1225-1243. [PMID: 32581529 PMCID: PMC7276323 DOI: 10.2147/copd.s244942] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
Analytic epidemiological studies cover a large spectrum of study methodologies, ranging from noninterventional observational studies (population-based, case-control, or cohort studies) to interventional studies (clinical trials). Herein, we review the different research methodologies or study designs and discuss their advantages and disadvantages in the context of chronic obstructive pulmonary disease (COPD) pharmacotherapy. Although randomized controlled trials (RCTs) are considered the "gold standard" for evaluating the efficacy and safety of an intervention, observational studies conducted in a real-world scenario are useful in providing evidence on the effectiveness of the intervention in clinical practice; understanding both efficacy and effectiveness is important from the clinician's perspective. Pragmatic clinical trials that use real-world data while retaining randomization bridge the gap between explanatory RCTs and noninterventional observational studies. Overall, different study designs have their associated advantages and disadvantages; together, findings from all types of studies bring about progress in clinical research as elucidated through examples from COPD research in this paper.
Collapse
Affiliation(s)
- Donald P Tashkin
- The Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Alpesh N Amin
- Department of Medicine, School of Medicine University of California, Irvine, CA, USA
| | - Edward M Kerwin
- Crisor, LLC Clinical Research Institute of Southern Oregon, Medford, OR, USA
| |
Collapse
|
29
|
Calzetta L, Ritondo BL, Matera MG, Cazzola M, Rogliani P. Evaluation of fluticasone propionate/salmeterol for the treatment of COPD: a systematic review. Expert Rev Respir Med 2020; 14:621-635. [PMID: 32168461 DOI: 10.1080/17476348.2020.1743180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Introduction: Recently, the generic formulation of FP/SAL FDC has been approved in COPD. Although FP/SAL FDC has been the first long-acting FDC approved in COPD, no systematic review assessed the effect of this combination for the treatment of COPD by considering specifically Phase IV studies. The aim of this review was to systematically assess the effect of FP/SAL FDC in COPD patients enrolled in Phase IV studies.Areas covered: The question of this systematic review was to examine the evidence regarding the impact of FP/SAL FDC for the treatment of COPD by searching for Phase IV studies in the ClinicalTrials.gov database.Expert opinion: Generic drugs represent an effective cost-saving step for health-care budgets in the treatment of COPD and should be used in agreement with current recommendations and prescription accuracy. FP/SAL FDC is recommended for the initiation therapy just in a small percentage of symptomatic patients that are at high risk of exacerbation with blood eosinophil counts ≥300 cells per μl. At follow-up, FP/SAL FDC can be escalated to triple ICS/LABA/LAMA combination or switched to LABA/LAMA combination by considering symptoms, exacerbations, lack of response to ICS, inappropriate original indication, and ICS-related adverse events such as pneumonia.
Collapse
Affiliation(s)
- Luigino Calzetta
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | | | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| |
Collapse
|
30
|
Bloom CI, Douglas I, Usmani OS, Quint JK. Inhaled Corticosteroid Treatment Regimens and Health Outcomes in a UK COPD Population Study. Int J Chron Obstruct Pulmon Dis 2020; 15:701-710. [PMID: 32308379 PMCID: PMC7136662 DOI: 10.2147/copd.s241568] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/10/2020] [Indexed: 01/23/2023] Open
Abstract
Background Inhaled corticosteroids (ICS) are a prevailing treatment option for COPD patients but recent guidelines have relegated their use predominantly to patients with frequent exacerbations. Yet large numbers of patients worldwide are currently treated with ICS-containing regimens. We wished to determine in routine clinical practice how common ICS withdrawal is and the differences in health outcomes between patients managed on ICS-containing and non-ICS containing regimens. Patients and Methods COPD patients were identified from the UK primary care electronic healthcare records, between 2014 and 2018. Patients were grouped into three treatment regimens: long-acting beta-agonist (LABA) and inhaled corticosteroids (ICS), LABA and long-acting muscarinic antagonist (LAMA), and triple therapy (LABA, LAMA and ICS). Annual incidence of ICS withdrawal was measured. Multivariable logistic regression was used to identify patient factors associated with withdrawal. Multivariable Poisson regression was used to assess the association of exacerbations and hospitalised pneumonia between the ICS-containing regimens (LABA-ICS and triple therapy) and patients prescribed LABA-LAMA. Results Of 117,046 patients, around three-quarters were prescribed ICS-containing inhalers but ICS withdrawal occurred annually in only approximately 2–3% of patients. Exacerbations in the past year, but not a past history of pneumonia, were associated with ICS withdrawal. A total of 31,034 patients using three treatment regimens (LABA-ICS, LABA-LAMA or triple therapy) were assessed for their relative risk of exacerbations and pneumonia; the exacerbation risk was slightly lower in LABA-ICS users but the same in triple therapy users, as compared to LABA-LAMA users (LABA-ICS adjusted IRR=0.82 (95% CI 0.73–0.93), triple adjusted IRR=0.99 (95% CI 0.88–1.11)). There was no difference in the pneumonia risk (LABA-ICS adjusted IRR=0.96 (95% CI 0.71–1.31), triple adjusted IRR=1.16 (95% CI 0.87–1.57)). Conclusion Use of ICS-containing inhaled medication is prevalent across the UK while ICS withdrawal from established treatment was relatively uncommon. Exacerbations and pneumonia risk was similar between the ICS-containing and non-ICS containing treatment regimens.
Collapse
Affiliation(s)
- Chloe I Bloom
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
| | - Ian Douglas
- London School of Hygiene and Tropical Medicine, London, UK
| | - Omar S Usmani
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
| | - Jennifer K Quint
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
| |
Collapse
|
31
|
Jo T, Yasunaga H, Yamauchi Y, Mitani A, Hiraishi Y, Hasegawa W, Sakamoto Y, Matsui H, Fushimi K, Nagase T. Inhaled corticosteroid withdrawal may improve outcomes in elderly patients with COPD exacerbation: a nationwide database study. ERJ Open Res 2020; 6:00246-2019. [PMID: 32039260 PMCID: PMC6995839 DOI: 10.1183/23120541.00246-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/27/2019] [Indexed: 01/04/2023] Open
Abstract
Background Inhaled corticosteroids (ICSs) are used for advanced-stage chronic obstructive pulmonary disease (COPD). The application and safety of ICS withdrawal remain controversial. This study aimed to evaluate the association between ICS withdrawal and outcomes in elderly patients with COPD with or without comorbid bronchial asthma, who were hospitalised for exacerbation. Patients and methods We conducted a retrospective cohort study using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2016. We identified patients aged ≥65 years who were hospitalised for COPD exacerbation. Re-hospitalisation for COPD exacerbation or death, frequency of antimicrobial medicine prescriptions and frequency of oral corticosteroid prescriptions after discharge were compared between patients with withdrawal and continuation of ICSs using propensity score analyses, namely 1–2 propensity score matching and stabilised inverse probability of treatment weighting. Results Among 3735 eligible patients, 971 and 2764 patients had ICS withdrawal and continuation, respectively. The hazard ratios (95% confidence intervals) of re-hospitalisation for COPD exacerbation or death for ICS withdrawal compared to continuation were 0.65 (0.52–0.80) in the propensity score matching and 0.71 (0.56–0.90) in the inverse probability of treatment weighting. The frequency of antimicrobial prescriptions but not corticosteroid prescriptions within 1 year was significantly less in the ICS withdrawal group. Among patients with comorbid bronchial asthma, ICS withdrawal was significantly associated with reduced re-hospitalisation for COPD exacerbation or death only in the propensity score matching analysis. Conclusion ICS withdrawal after COPD exacerbation was significantly associated with reduced incidences of re-hospitalisation or death among elderly patients, including those with comorbid bronchial asthma. ICS withdrawal after COPD exacerbation is significantly associated with reduced incidences of re-hospitalisation or death among elderly patients. ICS withdrawal may thus be considered as a treatment option in elderly patients with COPD.http://bit.ly/2rMg4wK
Collapse
Affiliation(s)
- Taisuke Jo
- Dept of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Dept of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Dept of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yasuhiro Yamauchi
- Dept of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akihisa Mitani
- Dept of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihisa Hiraishi
- Dept of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Wakae Hasegawa
- Dept of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiyo Sakamoto
- Dept of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Dept of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Dept of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Takahide Nagase
- Dept of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
32
|
Chapman KR, Hurst JR, Frent SM, Larbig M, Fogel R, Guerin T, Banerji D, Patalano F, Goyal P, Pfister P, Kostikas K, Wedzicha JA. Long-Term Triple Therapy De-escalation to Indacaterol/Glycopyrronium in Patients with Chronic Obstructive Pulmonary Disease (SUNSET): A Randomized, Double-Blind, Triple-Dummy Clinical Trial. Am J Respir Crit Care Med 2019; 198:329-339. [PMID: 29779416 DOI: 10.1164/rccm.201803-0405oc] [Citation(s) in RCA: 166] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE There are no studies on withdrawal of inhaled corticosteroids in patients on long-term triple therapy in the absence of frequent exacerbations. OBJECTIVES To evaluate the efficacy and safety of direct de-escalation from long-term triple therapy to indacaterol/glycopyrronium in nonfrequently exacerbating patients with chronic obstructive pulmonary disease (COPD). METHODS This 26-week, randomized, double-blind, triple-dummy study assessed the direct change from long-term triple therapy to indacaterol/glycopyrronium (110/50 μg once daily) or continuation of triple therapy (tiotropium [18 μg] once daily plus combination of salmeterol/fluticasone propionate [50/500 μg] twice daily) in nonfrequently exacerbating patients with moderate-to-severe COPD. Primary endpoint was noninferiority on change from baseline in trough FEV1. Moderate or severe exacerbations were predefined secondary endpoints. MEASUREMENTS AND MAIN RESULTS A total of 527 patients were randomized to indacaterol/glycopyrronium and 526 to triple therapy. Inhaled corticosteroids withdrawal led to a reduction in trough FEV1 of -26 ml (95% confidence interval, -53 to 1 ml) with confidence limits exceeding the noninferiority margin of -50 ml. The annualized rate of moderate or severe COPD exacerbations did not differ between treatments (rate ratio, 1.08; 95% confidence interval, 0.83 to 1.40). Patients with ≥300 blood eosinophils/μl at baseline presented greater lung function loss and higher exacerbation risk. Adverse events were similar in the two groups. CONCLUSIONS In patients with COPD without frequent exacerbations on long-term triple therapy, the direct de-escalation to indacaterol/glycopyrronium led to a small decrease in lung function, with no difference in exacerbations. The higher exacerbation risk in patients with ≥300 blood eosinophils/μl suggests that these patients are likely to benefit from triple therapy. Clinical trial registered with www.clinicaltrials.gov (NCT 02603393).
Collapse
Affiliation(s)
- Kenneth R Chapman
- 1 Asthma and Airway Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - John R Hurst
- 2 UCL Respiratory, University College London, London, United Kingdom
| | - Stefan-Marian Frent
- 3 Department of Pulmonology, University of Medicine and Pharmacy, Timisoara, Romania
| | | | - Robert Fogel
- 5 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Tadhg Guerin
- 6 Novartis Ireland Limited, Dublin, Ireland; and
| | - Donald Banerji
- 5 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | | | | | - Jadwiga A Wedzicha
- 7 Respiratory Clinical Science Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| |
Collapse
|
33
|
The Airways' Mechanical Stress in Lung Disease: Implications for COPD Pathophysiology and Treatment Evaluation. Can Respir J 2019; 2019:3546056. [PMID: 31583033 PMCID: PMC6748188 DOI: 10.1155/2019/3546056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/14/2019] [Indexed: 11/17/2022] Open
Abstract
The airway epithelium stretches and relaxes during the normal respiratory cycle, and hyperventilation exaggerates this effect, resulting in changes in lung physiology. In fact, stretching of the airways influences lung function and the secretion of airway mediators, which in turn may cause a potentially injurious inflammatory response. This aim of the present narrative review was to illustrate the current evidence on the importance of mechanical stress in the pathophysiology of lung diseases with a particular focus on chronic obstructive pulmonary disease (COPD) and to discuss how this may influence pharmacological treatment strategies. Overall, treatment selection should be tailored to counterpart the effects of mechanical stress, which influences inflammation both in asthma and COPD. The most suitable treatment approach between a long-acting β2-agonists/long-acting antimuscarinic-agonist (LABA/LAMA) alone or with the addition of inhaled corticosteroids should be determined based on the underlying mechanism of inflammation. Noteworthy, the anti-inflammatory effects of the glycopyrronium/indacaterol combination on hyperinflation and mucociliary clearance may decrease the rate of COPD exacerbations, and it may synergistically improve bronchodilation with a double action on both the cyclic adenosine monophosphate (cAMP) and the acetylcholine pathways.
Collapse
|
34
|
Avdeev S, Aisanov Z, Arkhipov V, Belevskiy A, Leshchenko I, Ovcharenko S, Shmelev E, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD patients: rationale and algorithms. Int J Chron Obstruct Pulmon Dis 2019; 14:1267-1280. [PMID: 31354256 PMCID: PMC6572750 DOI: 10.2147/copd.s207775] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/17/2019] [Indexed: 12/17/2022] Open
Abstract
Observational studies indicate that overutilization of inhaled corticosteroids (ICS) is common in patients with chronic obstructive pulmonary disease (COPD). Overprescription and the high risk of serious ICS-related adverse events make withdrawal of this treatment necessary in patients for whom the treatment-related risks outweigh the expected benefits. Elaboration of an optimal, universal, user-friendly algorithm for withdrawal of ICS therapy has been identified as an important clinical need. This article reviews the available evidence on the efficacy, risks, and indications of ICS in COPD, as well as the benefits of ICS treatment withdrawal in patients for whom its use is not recommended by current guidelines. After discussing proposed approaches to ICS withdrawal published by professional associations and individual authors, we present a new algorithm developed by consensus of an international group of experts in the field of COPD. This relatively simple algorithm is based on consideration and integrated assessment of the most relevant factors (markers) influencing decision-making, such a history of exacerbations, peripheral blood eosinophil count, presence of infection, and risk of community-acquired pneumonia.
Collapse
Affiliation(s)
- Sergey Avdeev
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation.,Clinical Department, Federal Pulmonology Research Institute, Federal Medical and Biological Agency of Russia, Moscow, Russian Federation
| | - Zaurbek Aisanov
- Department of Pulmonology, N.I. Pirogov Russian State National Research Medical University, Moscow, Russian Federation
| | - Vladimir Arkhipov
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Andrey Belevskiy
- Department of Pulmonology, N.I. Pirogov Russian State National Research Medical University, Moscow, Russian Federation
| | - Igor Leshchenko
- Department of Phthisiology, Pulmonology and Thoracic Surgery, Ural State Medical University, Ekaterinburg, Russian Federation
| | - Svetlana Ovcharenko
- Department of Internal Diseases No.1, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Evgeny Shmelev
- Department of Differential Diagnostics, Federal Central Research Institute of Tuberculosis, Moscow, Russian Federation
| | - Marc Miravitlles
- Pneumology Department, University Hospital Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| |
Collapse
|
35
|
de Miguel-Díez J, Jiménez-García R, López de Andrés A, Zaragoza Arnáez F. Effectiveness of an Intervention to Improve Management of COPD using the AUDIT Methodology: Results of the Neumo-Advance Study. Clin Drug Investig 2019; 39:653-664. [PMID: 31037610 DOI: 10.1007/s40261-019-00787-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE The implementation of chronic obstructive pulmonary disease (COPD) guidelines in the real-world setting remains low. Pulmonologists should participate in the new paradigms of chronicity of COPD, by providing their knowledge, expertise, innovation and research. The objective of this study was to survey pulmonologists on the adherence to COPD guidelines and to measure the change of attitude after holding meetings presenting the latest research on the subject. METHODS Fifty questions on COPD management were sent to 150 pulmonologists. Using the AUDIT methodology, the responses were discussed at several face-to-face meetings, held in different autonomous communities of Spain. The same questionnaire was subsequently sent to the participants and changes in their responses were analysed. RESULTS In total, 148 physicians (60.1% female) completed study. The main responses were: (1) 16.2% diagnose following clinical criteria; (2) 78.4% performed diagnostic tests other than spirometry; (3) 73.6% always determined alpha-1 antitrypsin levels (81.8% in the second questionnaire, p < 0.05); (4) 73% determined the patient's phenotype; (5) 42% always asked about passive exposure to cigarette smoke (55% after the meetings, p < 0.05); (6) 58.1% always asked about exposure to other pollutants or biomass; (7) 29.1% always assessed inhalational technique; (8) dual bronchodilators were the most common treatment (49.3%) used for patients with frequent exacerbator phenotype, glycopyrronium + indacaterol being the preferred option (44.1%); (9) 41.2% discontinued inhaled corticosteroids treatment (54.7% in the second questionnaire, p < 0.05); (10) for exacerbation admissions, 52% replaced maintenance bronchodilators with short-acting agents and introduced early background treatment (58.8% in the second round, p < 0.05). Few variations occurred in the participants' answers after the meetings. CONCLUSIONS The adherence of pulmonologists to clinical practice recommendations for COPD management is suboptimal. As well as face-to-face meetings, more intensive interventions are required to raise awareness on the importance of improving compliance with clinical guidelines.
Collapse
Affiliation(s)
- Javier de Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - Rodrigo Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas S/n, 28922, Alcorcón, Madrid, Spain
| | - Ana López de Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas S/n, 28922, Alcorcón, Madrid, Spain
| | | |
Collapse
|
36
|
Lee SH, Lee JH, Yoon HI, Park HY, Kim TH, Yoo KH, Oh YM, Jung KS, Lee SD, Lee SW. Change in inhaled corticosteroid treatment and COPD exacerbations: an analysis of real-world data from the KOLD/KOCOSS cohorts. Respir Res 2019; 20:62. [PMID: 30922302 PMCID: PMC6437901 DOI: 10.1186/s12931-019-1029-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/20/2019] [Indexed: 12/04/2022] Open
Abstract
Background This cohort study of patients with chronic obstructive pulmonary disease (COPD) was performed to evaluate the status of inhaled corticosteroid (ICS) prescriptions following the 2017 revision of the Global Initiative for Chronic Obstructive Lung Disease guidelines. Methods A total of 1144 patients from the Korean Obstructive Lung Disease and Korea Chronic Obstructive Pulmonary Disorders Subgroup Study cohorts, with final follow-up visits completed between 2017 and 2018, were analyzed. Features indicative of ICS usage were as follows: a history of asthma, blood eosinophils of ≥300 cells/μl, or ≥ 2 exacerbations in the year prior to enrollment. Among baseline ICS users, we compared annual total and severe exacerbation rates, based on ICS continuation or withdrawal. Results ICS-containing regimens were prescribed to 46.3% of the enrolled of patients in 2014; this decreased to 38.8% in 2017, and long-acting dual bronchodilators were used instead. Among ICS users in 2017, 47.5% did not exhibit features indicative of ICS usage; 478 used ICS at baseline, and ICS was withdrawn in 77 (16.1%) during the study period. The proportion of patients with asthma and the baseline annual exacerbation rate were greater in the ICS withdrawal groinup than in the ICS continued group (56.6% vs. 41%, p = 0.01; 0.79 vs. 0.53, p < 0.001). Annual exacerbation rates during the follow-up period were similar between the ICS-withdrawal and ICS -continued groups (0.48 vs. 0.47, p = 0.84); however, former exhibited a significantly higher rate of severe exacerbation (0.22 vs. 0.12, p = 0.03). Conclusions Prescriptions of ICS to treat COPD decreased with increased use of long-acting dual bronchodilators. ICS withdrawal might impact severe exacerbation; the potential risks and benefits of withdrawing ICS should therefore be considered based on patients’ characteristics.
Collapse
Affiliation(s)
- Se Hee Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae-Hyung Kim
- Division of Pulmonary and Critical Care Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ki Suk Jung
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical School, Anyang, Republic of Korea
| | - Sang-Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
37
|
Bloom CI, Elkin SL, Quint JK. Changes in COPD inhaler prescriptions in the United Kingdom, 2000 to 2016. Int J Chron Obstruct Pulmon Dis 2019; 14:279-287. [PMID: 30774325 PMCID: PMC6349076 DOI: 10.2147/copd.s190086] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Over the past two decades, there have been significant changes in the pharmacological management of COPD, due to an explosion of inhaler trials, and timely updation of national and international guidelines. We sought to describe temporal changes in prescribing practices in the United Kingdom, and some of the factors that may have influenced them. Patients and methods COPD patients were identified from UK primary care nationally representative electronic healthcare records (Clinical Practice Research Datalink), between 2000 and 2016. Prescription data were described by the three maintenance inhaled medication classes used, inhaled corticosteroids (ICS), long-acting beta agonist (LABA), long-acting muscarinic antagonist (LAMA), and their combinations, dual LABA-ICS, dual LAMA-LABA, or triple therapy LABA-ICS-LAMA. Differing patient characteristics across the six different therapy regimens were measured in 2016. Results COPD patients were identified: 187,588 prevalent and incident inhaler users and 169,511 incident inhaler users. Since 2002, LAMA showed increasing popularity, while ICS alone exhibited an inverse trend. Triple therapy prescriptions rapidly increased as the first-line therapy until 2014 when LAMA-LABA prescriptions started to increase. By 2014, 41% of all COPD patients were maintained on triple therapy, and 13% were maintained on LAMA only. Characterizing the patients in 2016 revealed that those on triple therapy were more likely to have more severe disease, yet, over a third of patients on triple therapy had only mild disease. Conclusion UK prescribing practices were not in keeping with national guidelines but did appear to align with evidence from major drug trials and updated international guidelines. There has been a huge upsurge in triple therapy but incident data show this trend is beginning to reverse for initial management.
Collapse
Affiliation(s)
- Chloe I Bloom
- National Heart and Lung Institute, Imperial College London, London SW3 6LR, UK,
| | - S L Elkin
- Department of Respiratory Medicine, Imperial College NHS Trust, London, UK
| | - J K Quint
- National Heart and Lung Institute, Imperial College London, London SW3 6LR, UK,
| |
Collapse
|
38
|
Kaplan A, Chapman KR, Anees SM, Mayers I, Rochdi D, Djandji M, Préfontaine D, McIvor A. Real-life effectiveness of indacaterol-glycopyrronium after switching from tiotropium or salmeterol/fluticasone therapy in patients with symptomatic COPD: the POWER study. Int J Chron Obstruct Pulmon Dis 2019; 14:249-260. [PMID: 30718952 PMCID: PMC6343749 DOI: 10.2147/copd.s185485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose In contrast to randomized controlled trials (RCTs), changes in maintenance pharmacotherapy in clinical practice occur without a washout period. The Prospective cohort study for the real-life effectiveness evaluation of glycOpyrronium With indacatERol combination in the management of COPD in Canada (POWER) study evaluated the real-life effectiveness of indacaterol/glycopyrronium (IND/GLY) following a direct switch from a long-acting muscarinic antagonist (LAMA, tiotropium) or long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) maintenance treatment (salmeterol/fluticasone [SFC]). Methods POWER was a single-cohort, prospective, multicenter, interventional study in which patients with moderate-to-severe COPD, who remained symptomatic on their current treatment of once-daily (od) tiotropium 18 µg or twice-daily (bid) SFC (any dose), were switched to treatment with open-label IND/GLY 110/50 µg od for 16 weeks. Effectiveness end points were change from baseline in trough FEV1, transition dyspnea index (TDI) total scores, and COPD assessment test (CAT) scores at 16 weeks. Results Trough FEV1 improved by 175 mL at Week 16 in patients who switched to IND/GLY. The change was 176 mL (95% CI: 135-217) when switched from tiotropium and 172 mL (95% CI: 85-258) when switched from SFC fixed-dose combination (FDC). At Week 16, significant improvements were observed in the mean TDI total scores (Δ=2.5) and CAT scores (Δ=-6.5) after the switch to IND/GLY treatment (both P<0.0001). Additionally, IND/GLY was well tolerated in patients with moderate-to-severe COPD, and no safety signal was observed. Conclusion In clinical practice settings, a direct switch from previous treatment with either tiotropium or SFC to IND/GLY was safe and provided superior clinically significant improvements in lung function and patient-related outcomes in patients with moderate-to-severe COPD. Clinical trial registration NCT02202616.
Collapse
Affiliation(s)
- Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, ON, Canada,
| | - Kenneth R Chapman
- Division of Respiratory Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Syed M Anees
- Schulich School of Medicine & Dentistry - Western University, University of Windsor, ON, Canada
| | - Irvin Mayers
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Driss Rochdi
- Novartis Pharmaceuticals Canada Inc., Montreal, QC, Canada
| | - Michel Djandji
- Novartis Pharmaceuticals Canada Inc., Montreal, QC, Canada
| | | | - Andrew McIvor
- Department of Medicine, McMaster University, Firestone Institute for Respiratory Health, Hamilton, ON, Canada
| |
Collapse
|
39
|
Current Controversies in Chronic Obstructive Pulmonary Disease. A Report from the Global Initiative for Chronic Obstructive Lung Disease Scientific Committee. Ann Am Thorac Soc 2019; 16:29-39. [DOI: 10.1513/annalsats.201808-557ps] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
|
40
|
Agusti A, Fabbri LM, Singh D, Vestbo J, Celli B, Franssen FME, Rabe KF, Papi A. Inhaled corticosteroids in COPD: friend or foe? Eur Respir J 2018; 52:13993003.01219-2018. [PMID: 30190269 DOI: 10.1183/13993003.01219-2018] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/23/2018] [Indexed: 12/28/2022]
Abstract
The efficacy, safety and positioning of inhaled corticosteroids (ICS) in the treatment of patients with chronic obstructive pulmonary disease (COPD) is much debated, since it can result in clear clinical benefits in some patients ("friend") but can be ineffective or even associated with undesired side effects, e.g. pneumonia, in others ("foe"). After critically reviewing the evidence for and against ICS treatment in patients with COPD, we propose that: 1) ICS should not be used as a single, stand-alone therapy in COPD; 2) patients most likely to benefit from the addition of ICS to long-acting bronchodilators include those with history of multiple or severe exacerbations despite appropriate maintenance bronchodilator use, particularly if blood eosinophils are >300 cells·µL-1, and those with a history of and/or concomitant asthma; and 3) the risk of pneumonia in COPD patients using ICS is higher in those with older age, lower body mass index (BMI), greater overall fragility, receiving higher ICS doses and those with blood eosinophils <100 cells·µL-1 All these factors must be carefully considered and balanced in any individual COPD patient before adding ICS to her/his maintenance bronchodilator treatment. Further research is needed to clarify some of these issues and firmly establish these recommendations.
Collapse
Affiliation(s)
- Alvar Agusti
- Respiratory Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBER Enfermedades Respiratorias, Spain
| | - Leonardo M Fabbri
- Dept of Medicine, University of Ferrara, Ferrara, Italy.,COPD Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dave Singh
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,Medicines Evaluation Unit, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Bartolome Celli
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Frits M E Franssen
- Dept of Research and Education, CIRO, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Hospital, Maastricht, The Netherlands
| | - Klaus F Rabe
- LungenClinic Großhansdorf, member of the German Center for Lung Research (DZL), Großhansdorf, Germany.,Christian Albrechts Universität Kiel, member of the German Center for Lung Research (DZL), Kiel, Germany
| | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| |
Collapse
|
41
|
Beeh KM, Kirsten AM, Tanase AM, Richard A, Cao W, Hederer B, Beier J, Kornmann O, van Zyl-Smit RN. Indacaterol acetate/mometasone furoate provides sustained improvements in lung function compared with salmeterol xinafoate/fluticasone propionate in patients with moderate-to-very-severe COPD: results from a Phase II randomized, double-blind 12-week study. Int J Chron Obstruct Pulmon Dis 2018; 13:3923-3936. [PMID: 30584293 PMCID: PMC6287650 DOI: 10.2147/copd.s179293] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background and purpose Fixed-dose combinations of a long-acting beta agonist and an inhaled corticosteroid are more effective than the individual components in COPD. The primary study objective was to demonstrate that the combination indacaterol acetate/mometasone furoate (IND/MF [QMF149]) was non-inferior to the twice-daily combination salmeterol xinafoate/fluticasone propionate (Sal/Flu) in terms of trough FEV1 at week 12 (day 85). Secondary objectives were to compare the efficacy of IND/MF (QMF149) vs Sal/Flu with respect to other lung function parameters, COPD exacerbations, symptoms and dyspnea, health status/health-related quality of life, and rescue medication use. Materials and methods This was a 12-week multicenter, randomized, double-blind, double-dummy, parallel-group, Phase II study in patients with moderate-to-very-severe COPD, who were randomized (1:1) to IND/MF (QMF149) (150/160 µg once daily; n=316) or Sal/Flu (50/500 µg twice daily; n=313). Results Over 90% of patients completed the study: 94.6% in the IND/MF (QMF149) group and 92.0% in the Sal/Flu group. The primary objective of non-inferiority of IND/MF (QMF149) to Sal/Flu for trough FEV1 at week 12 (day 85) was met: the lower limit of the CI (95% CI: 27.7, 83.3 mL) was greater than −60 mL. The analysis for superiority of IND/MF (QMF149) to Sal/Flu demonstrated superiority of IND/MF (QMF149), with a difference of 56 mL (P<0.001). In addition, IND/MF (QMF149) treatment significantly improved COPD exacerbation-related parameters during the 12-week period. Other significant improvements with IND/MF (QMF 149) vs Sal/Flu were noted for dyspnea at week 12 and other COPD symptoms and COPD rescue medication use over the 12 weeks. The safety and tolerability profiles of both the treatments were similar. Conclusion IND/MF (QMF149) (150/160 µg once daily) offered superior lung function and symptom efficacy and a favorable safety profile compared with Sal/Flu (50/500 µg twice daily) in patients with moderate-to-very severe COPD.
Collapse
Affiliation(s)
- Kai Michael Beeh
- Insaf Respiratory Research Institute Wiesbaden, Wiesbaden, Germany,
| | - Anne-Marie Kirsten
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | | | | | - Weihua Cao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Jutta Beier
- Insaf Respiratory Research Institute Wiesbaden, Wiesbaden, Germany,
| | - Oliver Kornmann
- IKF Pneumologie, Clinical Research Centre Respiratory Diseases, Frankfurt, Germany
| | - Richard N van Zyl-Smit
- Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
42
|
Oba Y, Keeney E, Ghatehorde N, Dias S. Dual combination therapy versus long-acting bronchodilators alone for chronic obstructive pulmonary disease (COPD): a systematic review and network meta-analysis. Cochrane Database Syst Rev 2018; 12:CD012620. [PMID: 30521694 PMCID: PMC6517098 DOI: 10.1002/14651858.cd012620.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Long-acting bronchodilators such as long-acting β-agonist (LABA), long-acting muscarinic antagonist (LAMA), and LABA/inhaled corticosteroid (ICS) combinations have been used in people with moderate to severe chronic obstructive pulmonary disease (COPD) to control symptoms such as dyspnoea and cough, and prevent exacerbations. A number of LABA/LAMA combinations are now available for clinical use in COPD. However, it is not clear which group of above mentioned inhalers is most effective or if any specific formulation works better than the others within the same group or class. OBJECTIVES To compare the efficacy and safety of available formulations from four different groups of inhalers (i.e. LABA/LAMA combination, LABA/ICS combination, LAMA and LABA) in people with moderate to severe COPD. The review will update previous systematic reviews on dual combination inhalers and long-acting bronchodilators to answer the questions described above using the strength of a network meta-analysis (NMA). SEARCH METHODS We identified studies from the Cochrane Airways Specialised Register, which contains several databases. We also conducted a search of ClinicalTrials.gov and manufacturers' websites. The most recent searches were conducted on 6 April 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs) that recruited people aged 35 years or older with a diagnosis of COPD and a baseline forced expiratory volume in one second (FEV1) of less than 80% of predicted. We included studies of at least 12 weeks' duration including at least two active comparators from one of the four inhaler groups. DATA COLLECTION AND ANALYSIS We conducted NMAs using a Bayesian Markov chain Monte Carlo method. We considered a study as high risk if recruited participants had at least one COPD exacerbation within the 12 months before study entry and as low risk otherwise. Primary outcomes were COPD exacerbations (moderate to severe and severe), and secondary outcomes included symptom and quality-of-life scores, safety outcomes, and lung function. We collected data only for active comparators and did not consider placebo was not considered. We assumed a class/group effect when a fixed-class model fitted well. Otherwise we used a random-class model to assess intraclass/group differences. We supplemented the NMAs with pairwise meta-analyses. MAIN RESULTS We included a total of 101,311 participants from 99 studies (26 studies with 32,265 participants in the high-risk population and 73 studies with 69,046 participants in the low-risk population) in our systematic review. The median duration of studies was 52 weeks in the high-risk population and 26 weeks in the low-risk population (range 12 to 156 for both populations). We considered the quality of included studies generally to be good.The NMAs suggested that the LABA/LAMA combination was the highest ranked treatment group to reduce COPD exacerbations followed by LAMA in the both populations.There is evidence that the LABA/LAMA combination decreases moderate to severe exacerbations compared to LABA/ICS combination, LAMA, and LABA in the high-risk population (network hazard ratios (HRs) 0.86 (95% credible interval (CrI) 0.76 to 0.99), 0.87 (95% CrI 0.78 to 0.99), and 0.70 (95% CrI 0.61 to 0.8) respectively), and that LAMA decreases moderate to severe exacerbations compared to LABA in the high- and low-risk populations (network HR 0.80 (95% CrI 0.71 to 0.88) and 0.87 (95% CrI 0.78 to 0.97), respectively). There is evidence that the LABA/LAMA combination reduces severe exacerbations compared to LABA/ICS combination and LABA in the high-risk population (network HR 0.78 (95% CrI 0.64 to 0.93) and 0.64 (95% CrI 0.51 to 0.81), respectively).There was a general trend towards a greater improvement in symptom and quality-of-life scores with the combination therapies compared to monotherapies, and the combination therapies were generally ranked higher than monotherapies.The LABA/ICS combination was the lowest ranked in pneumonia serious adverse events (SAEs) in both populations. There is evidence that the LABA/ICS combination increases the odds of pneumonia compared to LAMA/LABA combination, LAMA and LABA (network ORs: 1.69 (95% CrI 1.20 to 2.44), 1.78 (95% CrI 1.33 to 2.39), and 1.50 (95% CrI 1.17 to 1.92) in the high-risk population and network or pairwise OR: 2.33 (95% CI 1.03 to 5.26), 2.02 (95% CrI 1.16 to 3.72), and 1.93 (95% CrI 1.29 to 3.22) in the low-risk population respectively). There were significant overlaps in the rank statistics in the other safety outcomes including mortality, total, COPD, and cardiac SAEs, and dropouts due to adverse events.None of the differences in lung function met a minimal clinically important difference criterion except for LABA/LAMA combination versus LABA in the high-risk population (network mean difference 0.13 L (95% CrI 0.10 to 0.15). The results of pairwise meta-analyses generally agreed with those of the NMAs. There is no evidence to suggest intraclass/group differences except for lung function at 12 months in the high-risk population. AUTHORS' CONCLUSIONS The LABA/LAMA combination was the highest ranked treatment group to reduce COPD exacerbations although there was some uncertainty in the results. LAMA containing inhalers may have an advantage over those without a LAMA for preventing COPD exacerbations based on the rank statistics. Combination therapies appear more effective than monotherapies for improving symptom and quality-of-life scores. ICS-containing inhalers are associated with an increased risk of pneumonia.Our most comprehensive review including intraclass/group comparisons, free combination therapies, 99 studies, and 20 outcomes for each high- and low-risk population summarises the current literature and could help with updating existing COPD guidelines.
Collapse
Affiliation(s)
- Yuji Oba
- University of MissouriDivision of Pulmonary and Critical Care MedicineColumbiaMOUSA
| | - Edna Keeney
- University of BristolPopulation Health Sciences, Bristol Medical SchoolBristolUK
| | - Namratta Ghatehorde
- University of MissouriDivision of Pulmonary and Critical Care MedicineColumbiaMOUSA
| | - Sofia Dias
- University of YorkCentre for Reviews and DisseminationHeslingtonYorkUKYO10 5DD
| | | |
Collapse
|
43
|
Beeh KM. And Then There Were Three: Time to Move Onward in COPD Drug Development Beyond LAMA/LABA/ICS at Last? Pulm Ther 2018; 4:115-119. [PMID: 32026390 PMCID: PMC6966987 DOI: 10.1007/s41030-018-0059-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kai M Beeh
- Insaf Respiratory Research Institute, Wiesbaden, Germany.
| |
Collapse
|
44
|
Diamant Z, Brusselle G, Russell RE. Toward effective prescription of inhaled corticosteroids in chronic airway disease. Int J Chron Obstruct Pulmon Dis 2018; 13:3419-3424. [PMID: 30425471 PMCID: PMC6203111 DOI: 10.2147/copd.s174216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Zuzana Diamant
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden.,Department of Clinical Pharmacy & Pharmacology University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.,QPS-Netherlands, University Medical Centre Groningen, Groningen, the Netherlands
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Richard E Russell
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK, .,Lymington New Forest Hospital, Southern Health National Health Service Foundation Trust, Lymington, Hampshire, UK,
| |
Collapse
|
45
|
Abstract
Inhaled corticosteroids represent the mainstay of pharmacological treatment for reversible airways disease, and traditionally have had widespread use in non-reversible chronic obstructive pulmonary disease (COPD). However, use in this group may expose patients to an increased risk of pneumonia, without significant benefit to symptoms or exacerbation frequency. Here we provide a guide to the use of inhaled therapy in COPD for the general physician.
Collapse
|
46
|
Scalone G, Nava S, Ventrella F, Bussoli G, Catapano GA, Pennisi A, Dadduzio F, Schino P, Pela R, Bartezaghi M, Morini P, Porpiglia PA, Muscianisi E. Pharmacological approach and adherence to treatment recommendations in frequently and non-frequently exacerbating COPD patients from Italy: MISTRAL - The prospective cohort, observational study. Pulm Pharmacol Ther 2018; 53:68-77. [PMID: 30193866 DOI: 10.1016/j.pupt.2018.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/02/2018] [Accepted: 09/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several documents and guidelines provide recommendations for effective management of COPD patients. However, there is often a significant imbalance between recommended treatment of COPD patients and the actual care provided both in primary care and specialty setting. This imbalance could result in a significant negative impact on patients' health status and quality of life, leading to increased hospitalisations and health resource utilisation in COPD patients METHODS: MISTRAL was an observational, longitudinal, prospective cohort study, designed to assess the overall pharmacological approach of COPD in routine clinical practice in Italy. Eligible patients were divided into two cohorts based on their exacerbation history in the year prior to the enrolment, frequent exacerbators (FEs; ≥2 exacerbations), and non-frequent exacerbators (NFEs; ≤1 exacerbation). The primary objective was to assess adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 treatment recommendations in FEs and NFEs at baseline and follow-up visits RESULTS: Of the 1489 enrolled patients, 1468 (98.6%; FEs, 526; NFEs, 942) were considered evaluable for analyses. At baseline, 57.8% of patients were treated according to GOLD 2011 recommendations; a greater proportion of FEs were treated according to GOLD recommendations, compared with NFEs patients at baseline (77.1% versus 46.7%; P < 0.0001), and all study visits. At baseline, GOLD group D patients were the most adherent (81.2%) to treatment recommendations, while group A patients were the least adherent (30.3%) at baseline, attributed mainly to overuse of inhaled corticosteroids in less severe GOLD groups. Triple therapy with long-acting muscarinic antagonist (LAMA) + long-acting β2-agonist/inhaled corticosteroid (LABA/ICS) was the most frequent prescribed treatment at all study visits, irrespective of patient's exacerbation history. Changes in treatment were more frequent in FEs versus NFEs CONCLUSIONS: The Mistral study reports a scarce adherence to the GOLD 2011 treatment recommendations in routine clinical practice in Italy. The adherence was particularly low in less severe, non-frequent exacerbating patients mostly for ICS overuse, and was higher in high-risk, frequent exacerbating COPD patients.
Collapse
Affiliation(s)
- Gino Scalone
- Respiratory Pathophysiology Service - House of Health, Chiaravalle C.le (CZ), Italy.
| | - Stefano Nava
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Bologna, Italy.
| | - Francesco Ventrella
- Department of Internal Medicine - G.Tatarella Hospital, Cerignola, Foggia, Italy.
| | - Guglielmo Bussoli
- Pneumology Service at Cittadella Socio-sanitaria- Cavarzere, Venice, Italy.
| | - Giosuè Angelo Catapano
- Pneumology Unit, G. Monasterio Tuscany Foundation/National Research Council, Pisa, Italy.
| | - Alfio Pennisi
- Respiratory Service Phisiopatology Rehab Center, Monsignor Goose, Calaciura, Biancavilla, Catania, Italy.
| | | | - Pietro Schino
- UO Pulmonary Fisiopathology, Miulli General Hospital, Acquaviva delle Fonti (BA), Italy.
| | - Riccardo Pela
- Pneumology Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy.
| | | | | | | | | | | |
Collapse
|
47
|
Tashkin DP. To Withdraw or Not to Withdraw Inhaled Corticosteroids from Triple Therapy in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2018; 198:292-294. [DOI: 10.1164/rccm.201805-0979ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Donald P. Tashkin
- David Geffen School of Medicine at UCLAUniversity of California, Los AngelesLos Angeles, California
| |
Collapse
|
48
|
Cataldo D, Derom E, Liistro G, Marchand E, Ninane V, Peché R, Slabbynck H, Vincken W, Janssens W. Overuse of inhaled corticosteroids in COPD: five questions for withdrawal in daily practice. Int J Chron Obstruct Pulmon Dis 2018; 13:2089-2099. [PMID: 30013336 PMCID: PMC6039066 DOI: 10.2147/copd.s164259] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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
Evidence and guidelines are becoming increasingly clear about imbalance between the risks and benefits of inhaled corticosteroids (ICSs) in patients with COPD. While selected patients may benefit from ICS-containing regimens, ICSs are often inappropriately prescribed with - according to Belgian market research data - up to 70% of patients in current practice receiving ICSs, usually as a fixed combination with a long-acting β2-adrenoreceptor agonist. Studies and recommendations support withdrawal of ICSs in a large group of patients with COPD. However, historical habits appear difficult to change even in the light of recent scientific evidence. We have built a collaborative educational platform with chest physicians and primary care physicians to increase awareness and provide guidance and support in this matter.
Collapse
Affiliation(s)
- Didier Cataldo
- Department of Respiratory Medicine, Centre Hospitalier Universitaire de Liège (CHU) and University of Liège, Liège, Belgium,
| | - Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Gent, Belgium
| | - Giuseppe Liistro
- Department of Respiratory Medicine, University Hospitals Saint-Luc, Brussels, Belgium
| | - Eric Marchand
- Department of Respiratory Medicine, University Hospital UCL Namur, Yvoir, Belgium
- URPhyM, University of Namur, Namur, Belgium
| | - Vincent Ninane
- Department of Respiratory Medicine, University Hospital Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Rudi Peché
- Department of Respiratory Medicine, University Hospital Vésale, Montigny-le-Tilleul, Belgium
| | - Hans Slabbynck
- Department of Respiratory Medicine, ZNA Middelheim, Antwerpen, Belgium
| | - Walter Vincken
- Respiratory Division, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | - Wim Janssens
- Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
49
|
Harrison A, Borg B, Thompson B, Hew M, Dabscheck E. Inappropriate inhaled corticosteroid prescribing in chronic obstructive pulmonary disease patients. Intern Med J 2018; 47:1310-1313. [PMID: 29105270 DOI: 10.1111/imj.13611] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 02/06/2017] [Accepted: 02/06/2017] [Indexed: 12/31/2022]
Abstract
The Australian National Chronic Obstructive Pulmonary Disease (COPD) guidelines recommend that inhaled corticosteroids (ICS) be reserved for patients with a post-bronchodilator forced expiratory volume in 1 s (FEV1 ) less than 50% predicted and those who experience ≥2 exacerbations in 12 months. In total, 707 COPD patients were identified from the lung function test database at our tertiary hospital; 52.4% of patients with a post-bronchodilator FEV1 ≥50% were prescribed an ICS. Significant discordance exists between guideline recommendations and inhaler prescription.
Collapse
Affiliation(s)
- Amelia Harrison
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Brigitte Borg
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Bruce Thompson
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Hew
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
50
|
Lopez-Campos JL, Carrasco Hernández L, Muñoz X, Bustamante V, Barreiro E. Current controversies in the stepping up and stepping down of inhaled therapies for COPD at the patient level. Respirology 2018; 23:818-827. [PMID: 29924458 DOI: 10.1111/resp.13341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 12/23/2022]
Abstract
The implementation of potential new step-up or step-down treatment recommendations in response to current guidelines is one of the main challenges currently faced in actual daily practice settings. In the present narrative review, we aim to discuss the relevance of these step-up and step-down proposals at the patient level in daily clinical practice. In particular, we aim to review the challenges associated with inhaled maintenance therapy for chronic obstructive pulmonary disease (COPD) in four clinical scenarios. First, we discuss the step up from single to double bronchodilation, including current controversies regarding the addition of a second bronchodilator versus initial treatment with two bronchodilators. Second, we discuss the step up from double bronchodilation to triple therapy while challenging current indications for inhaled steroid therapy and discussing triple therapy designs. Third, we discuss the step down from triple therapy to double bronchodilation while evaluating the effect of this downshift in risk categories on the patient according to the new classifications. Finally, we discuss the step down from double to single bronchodilation, with a special focus on safety. We believe this review will help to highlight the most relevant discussion points regarding the treatment of COPD in a manner that will stimulate and guide related clinical research.
Collapse
Affiliation(s)
- Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Laura Carrasco Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Xavier Muñoz
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Service, Department of Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Víctor Bustamante
- Servicio de Neumología, Hospital Universitario Basurto, Osakidetza, Departamento de Medicina, EHU-University of the Basque Country, Vizcaya, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department (CEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
| |
Collapse
|