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Nishimura K, Kusunose M, Sanda R, Shibayama A, Nakayasu K. Frailty and Exacerbation of Chronic Obstructive Pulmonary Disease: Is There Any Association? Int J Chron Obstruct Pulmon Dis 2024; 19:1131-1139. [PMID: 38807967 PMCID: PMC11131955 DOI: 10.2147/copd.s455316] [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: 12/19/2023] [Accepted: 05/14/2024] [Indexed: 05/30/2024] Open
Abstract
Purpose This study investigated if individuals with chronic obstructive pulmonary disease (COPD) and frailty are more likely to have acute exacerbations of COPD or require hospitalization for exacerbation than those without frailty. Patients and Methods Data on 135 outpatients with stable COPD were analyzed with the Cox proportional hazards model to assess the risk of future events. The Kihon Checklist was administered at baseline to classify the participants as robust, pre-frail, or frail. The follow-up period was a maximum of six and a half years. Results In all, 76 patients (56.3%) experienced an exacerbation and 46 (34.1%) were hospitalized due to it. Multivariate Cox proportional hazards analysis that accounted for FEV1 and sex showed that the frail group was more likely to face future risks of COPD exacerbations [Hazard ratio 1.762 (95% CI 1.011-3.070), p=0.046] and hospitalizations for exacerbation [2.238 (1.073-4.667), p=0.032] than the robust group. No significant differences were observed when comparing robust patients to those who were pre-frail or pre-frail to frail either in exacerbations or hospitalizations. When comparing the C-indices for frailty and FEV1, the former index (exacerbation 0.591 and hospitalization 0.663) did not exceed the latter (0.663 and 0.769) in either analysis. Conclusion Frail COPD patients have a more unfavorable future risk of acute exacerbations of COPD and hospitalizations for exacerbation than robust patients. However, no significant differences were observed when comparing robust patients to those who were pre-frail or pre-frail to frail, suggesting that the future risk for COPD patients with frailty is only higher compared to those who are considered robust. Additionally, FEV1 was found to be a more reliable predictor of future events than measures of frailty.
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Affiliation(s)
- Koichi Nishimura
- National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
- Clinic Nishimura, Ayabe, Kyoto, Japan
| | - Masaaki Kusunose
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Ryo Sanda
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Ayumi Shibayama
- Department of Nursing, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
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Kanwal H, Khan S, Eldesoky GE, Mushtaq S, Khan A. Management of COPD and Comorbidities in COPD patients by Dispensing Pharmaceutical Care following Global Initiative for chronic Obstructive Lung Disease-Guidelines (GOLD guidelines 2020): A study protocol for a Prospective Randomized Clinical Trial. Heliyon 2023; 9:e21539. [PMID: 37942165 PMCID: PMC10628705 DOI: 10.1016/j.heliyon.2023.e21539] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/14/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
COPD (chronic obstructive pulmonary disease) is a medical condition that encompasses several chronic, progressive, and severe respiratory illnesses, such as emphysema and chronic bronchitis. COPD is the 4th most deadly disease in the world and its prevalence is expected to increase. Despite the abundance of information on the disease's etiology, pathophysiology, and treatment possibilities, it has long been underdiagnosed and underreported for a long time, particularly in developing countries. The symptoms of COPD result in significant impairments and significant impact on quality of life. COPD is the third leading cause of death in Pakistan. According to the published literature, COPD has been found to be associated with a serious economic burden, either the direct cost to healthcare systems in the form of frequent hospital admissions or indirect costs to patients suffering from COPD. Despite the availability of excellent medication, COPD treatment goals are frequently not achieved resulting in poor management of COPD. The recent studies revealed that due to the missing role of Pharmacists in most of the public sector hospitals of Pakistan, the COPD disease management protocols are not being properly followed. Pharmacists can help the healthcare system by implementing these management protocols that focus on patient education about the disease, prescribed medications, and proper inhalation techniques. Furthermore, the pharmacists as an effective healthcare's team member properly educate the patients about the ongoing assessments and their willingness to follow treatment recommendations and quit smoking, while referring them to smoking cessation programs as needed, following the GOLD guidelines. This aim of this clinical trial is to evaluate the impact of implementing standard treatment guidelines and the role of pharmacists in implementing GOLD guidelines for COPD management.
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Affiliation(s)
- Hafsa Kanwal
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Shahzeb Khan
- Centre for Pharmaceutical Engineering, Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, West Yorkshire, BD7, 1DP, UK
| | - Gaber E. Eldesoky
- Department of Chemistry, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Saima Mushtaq
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences (ASAB), National University of Sciences and Technology (NUST), Islamabad, Pakistan
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
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3
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Yang IA, Ferry OR, Clarke MS, Sim EH, Fong KM. Inhaled corticosteroids versus placebo for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2023; 3:CD002991. [PMID: 36971693 PMCID: PMC10042218 DOI: 10.1002/14651858.cd002991.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much uncertainty. COPD clinical guidelines currently recommend selective use of ICS. ICS are not recommended as monotherapy for people with COPD, and are only given in combination with long-acting bronchodilators due to greater efficacy of combination therapy. Incorporating and critiquing newly published placebo-controlled trials into the monotherapy evidence base may help to resolve ongoing uncertainties and conflicting findings about their role in this population. OBJECTIVES To evaluate the benefits and harms of inhaled corticosteroids, used as monotherapy versus placebo, in people with stable COPD, in terms of objective and subjective outcomes. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was October 2022. SELECTION CRITERIA We included randomised trials comparing any dose of any type of ICS, given as monotherapy, with a placebo control in people with stable COPD. We excluded studies of less than 12 weeks' duration and studies of populations with known bronchial hyper-responsiveness (BHR) or bronchodilator reversibility. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our a priori primary outcomes were 1. exacerbations of COPD and 2. quality of life. Our secondary outcomes were 3. all-cause mortality, 4. lung function (rate of decline of forced expiratory volume in one second (FEV1)), 5. rescue bronchodilator use, 6. exercise capacity, 7. pneumonia and 8. adverse events including pneumonia. ]. We used GRADE to assess certainty of evidence. MAIN RESULTS Thirty-six primary studies with 23,139 participants met the inclusion criteria. Mean age ranged from 52 to 67 years, and females were 0% to 46% of participants. Studies recruited across the severities of COPD. Seventeen studies were of duration longer than three months and up to six months and 19 studies were of duration longer than six months. We judged the overall risk of bias as low. Long-term (more than six months) use of ICS as monotherapy reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: rate ratio 0.88 exacerbations per participant per year, 95% confidence interval (CI) 0.82 to 0.94; I2 = 48%, 5 studies, 10,097 participants; moderate-certainty evidence; pooled means analysis: mean difference (MD) -0.05 exacerbations per participant per year, 95% CI -0.07 to -0.02; I2 = 78%, 5 studies, 10,316 participants; moderate-certainty evidence). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60; I2 = 0%; 5 studies, 2507 participants; moderate-certainty evidence; minimal clinically importance difference 4 points). There was no evidence of a difference in all-cause mortality in people with COPD (odds ratio (OR) 0.94, 95% CI 0.84 to 1.07; I2 = 0%; 10 studies, 16,636 participants; moderate-certainty evidence). Long-term use of ICS reduced the rate of decline in FEV1 in people with COPD (generic inverse variance analysis: MD 6.31 mL/year benefit, 95% CI 1.76 to 10.85; I2 = 0%; 6 studies, 9829 participants; moderate-certainty evidence; pooled means analysis: 7.28 mL/year, 95% CI 3.21 to 11.35; I2 = 0%; 6 studies, 12,502 participants; moderate-certainty evidence). ADVERSE EVENTS in the long-term studies, the rate of pneumonia was increased in the ICS group, compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.38, 95% CI 1.02 to 1.88; I2 = 55%; 9 studies, 14,831 participants; low-certainty evidence). There was an increased risk of oropharyngeal candidiasis (OR 2.66, 95% CI 1.91 to 3.68; 5547 participants) and hoarseness (OR 1.98, 95% CI 1.44 to 2.74; 3523 participants). The long-term studies that measured bone effects generally showed no major effect on fractures or bone mineral density over three years. We downgraded the certainty of evidence to moderate for imprecision and low for imprecision and inconsistency. AUTHORS' CONCLUSIONS This systematic review updates the evidence base for ICS monotherapy with newly published trials to aid the ongoing assessment of their role for people with COPD. Use of ICS alone for COPD likely results in a reduction of exacerbation rates of clinical relevance, probably results in a reduction in the rate of decline of FEV1 of uncertain clinical relevance and likely results in a small improvement in health-related quality of life not meeting the threshold for a minimally clinically important difference. These potential benefits should be weighed up against adverse events (likely to increase local oropharyngeal adverse effects and may increase the risk of pneumonia) and probably no reduction in mortality. Though not recommended as monotherapy, the probable benefits of ICS highlighted in this review support their continued consideration in combination with long-acting bronchodilators. Future research and evidence syntheses should be focused in that area.
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Affiliation(s)
- Ian A Yang
- Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
- UQ Thoracic Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Olivia R Ferry
- UQ Thoracic Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Melissa S Clarke
- Redcliffe Hospital, Redcliffe, Australia
- North Lakes Health Precinct, North Lakes, Australia
- Caboolture Community and Oral Health, Caboolture, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Kwun M Fong
- Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
- UQ Thoracic Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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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.
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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
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5
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Practical Recommendations for a Selection of Inhaled Corticosteroids in COPD: A Composite ICO Chart. Biomolecules 2023; 13:biom13020213. [PMID: 36830583 PMCID: PMC9953425 DOI: 10.3390/biom13020213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/25/2023] Open
Abstract
The use of inhaled corticosteroids (ICS) for the maintenance of bronchodilator treatment in patients with chronic obstructive pulmonary disease (COPD) is controversial. While some patients achieve clinical benefits, such as fewer exacerbations and improved symptoms, others do not, and some experience undesired side effects, such as pneumonia. Thus, we reviewed the evidence related to predictors of ICS therapy treatment response in patients with COPD. The first priority clinical markers when considering the efficacy of ICS are type 2 inflammatory biomarkers, followed by a history of suspected asthma and recurrent exacerbations. It is also necessary to consider any potential infection risk associated with ICS, and several risk factors for pneumonia when using ICS have been clarified in recent years. In this article, based on the evidence supporting the selection of ICS for COPD, we propose an ICS composite that can be added to the COPD (ICO) chart for use in clinical practice. The chart divided the type 2 biomarkers into three ranges and provided recommendations (recommend, consider, and against) by combining the history of suspected asthma, history of exacerbations, and risk of infection.
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6
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Wing K, Williamson E, Carpenter JR, Wise L, Schneeweiss S, Smeeth L, Quint JK, Douglas I. Medications for chronic obstructive pulmonary disease: a historical non-interventional cohort study with validation against RCT results. Health Technol Assess 2021; 25:1-70. [PMID: 34463610 DOI: 10.3310/hta25510] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease treatment is informed by randomised controlled trial results, but it is unclear if these findings apply to people excluded from these trials. We used data from the TORCH (TOwards a Revolution in COPD Health) randomised controlled trial to validate non-interventional methods for assessing the clinical effectiveness of chronic obstructive pulmonary disease treatment in the UK Clinical Practice Research Datalink, before applying these methods to the analysis of people who would have been excluded from TORCH. OBJECTIVES To validate the use of non-interventional Clinical Practice Research Datalink data and methods for estimating chronic obstructive pulmonary disease treatment effects against trial results, and, using validated methods, to determine treatment effects in people who would have been excluded from the TORCH trial. DESIGN A historical non-interventional cohort design, including validation against randomised controlled trial results. SETTING The UK Clinical Practice Research Datalink. PARTICIPANTS People aged ≥ 18 years with chronic obstructive pulmonary disease registered in Clinical Practice Research Datalink GOLD between January 2000 and January 2017. For objective 1, we prepared a cohort that was analogous to the TORCH trial cohort by applying TORCH trial inclusion/exclusion criteria followed by individual matching to TORCH trial participants. For objectives 2 and 3, we prepared cohorts that were analogous to the TORCH trial that, nevertheless, would not have been eligible for the TORCH trial because of age, asthma, comorbidity or mild disease. INTERVENTIONS The long-acting beta-2 agonist and inhaled corticosteroid combination product Seretide (GlaxoSmithKline plc) [i.e. fluticasone propionate plus salmeterol (FP-SAL)] compared with (1) no FP-SAL exposure or (2) exposure to salmeterol (i.e. the long-acting beta-2 agonist) only. MAIN OUTCOME MEASURES Exacerbations, mortality, pneumonia and time to treatment change. RESULTS For objective 1, the exacerbation rate ratio was comparable to that in the TORCH trial for FP-SAL compared with salmeterol (0.85, 95% confidence interval 0.74 to 0.97, vs. TORCH trial 0.88, 95% confidence interval 0.81 to 0.95), but not for FP-SAL compared with no FP-SAL (1.30, 95% confidence interval 1.19 to 1.42, vs. TORCH trial 0.75, 95% confidence interval 0.69 to 0.81). Active comparator results were also consistent with the TORCH trial for mortality (hazard ratio 0.93, 95% confidence interval 0.65 to 1.32, vs. TORCH trial hazard ratio 0.93, 95% confidence interval 0.77 to 1.13) and pneumonia (risk ratio 1.39, 95% confidence interval 1.04 to 1.87, vs. TORCH trial risk ratio 1.47, 95% confidence interval 1.25 to 1.73). For objectives 2 and 3, active comparator results were consistent with the TORCH trial for exacerbations, with the exception of people with milder chronic obstructive pulmonary disease, in whom we observed a stronger protective association (risk ratio 0.56, 95% confidence interval 0.46 to 0.70, vs. TORCH trial risk ratio 0.85, 95% confidence interval 0.74 to 0.97). For the analysis of mortality, we saw a lack of association with being prescribed FP-SAL (vs. being prescribed salmeterol), with the exception of those with prior asthma, for whom we observed an increase in mortality (hazard ratio 1.49, 95% confidence interval 1.21 to 1.85, vs. TORCH trial-analogous HR 0.93, 95% confidence interval 0.64 to 1.32). CONCLUSIONS Routinely collected electronic health record data can be used to successfully measure chronic obstructive pulmonary disease treatment effects when comparing two treatments, but not for comparisons between active treatment and no treatment. Analyses involving patients who would have been excluded from trials mostly suggests that treatment effects for FP-SAL are similar to trial effects, although further work is needed to characterise a small increased risk of death in those with concomitant asthma. LIMITATIONS Some of our analyses had small numbers. FUTURE WORK The differences in treatment effects that we found should be investigated further in other data sets. Currently recommended chronic obstructive pulmonary disease inhaled combination therapy (other than FP-SAL) should also be investigated using these methods. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 51. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kevin Wing
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - James R Carpenter
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Lesley Wise
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Sebastian Schneeweiss
- Department of Epidemiology, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Liam Smeeth
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ian Douglas
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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7
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Choi JY, Rhee CK. Diagnosis and Treatment of Early Chronic Obstructive Lung Disease (COPD). J Clin Med 2020; 9:jcm9113426. [PMID: 33114502 PMCID: PMC7692717 DOI: 10.3390/jcm9113426] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 12/16/2022] Open
Abstract
Chronic obstructive lung disease (COPD) is responsible for substantial rates of mortality and economic burden, and is one of the most important public-health concerns. As the disease characteristics include irreversible airway obstruction and progressive lung function decline, there has been a great deal of interest in detection at the early stages of COPD during the “at risk” or undiagnosed preclinical stage to prevent the disease from progressing to the overt stage. Previous studies have used various definitions of early COPD, and the term mild COPD has also often been used. There has been a great deal of recent effort to establish a definition of early COPD, but comprehensive evaluation is still required, including identification of risk factors, various physiological and radiological tests, and clinical manifestations for diagnosis of early COPD, considering the heterogeneity of the disease. The treatment of early COPD should be considered from the perspective of prevention of disease progression and management of clinical deterioration. There has been a lack of studies on this topic as the definition of early COPD has been proposed only recently, and therefore further clinical studies are needed.
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Affiliation(s)
- Joon Young Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
- Correspondence: ; Tel.: +82-2-2258-6067; Fax: +82-2-599-3589
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Albertson TE, Chenoweth JA, Pearson SJ, Murin S. The pharmacological management of asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). Expert Opin Pharmacother 2020; 21:213-231. [PMID: 31955671 DOI: 10.1080/14656566.2019.1701656] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) is a disease phenotype that shares T helper lymphocyte cell Th1/neutrophilic/non-Type-2 Inflammation pathways thought to be key in COPD and Th2/eosinophilic/Type-2 inflammatory pathways of asthma. The pharmacology of treating ACOS is challenging in severe circumstances.Areas covered: This review evaluates the stepwise treatment of ACOS using pharmacological treatments used in both COPD and asthma. The most common medications involve the same inhalers used to treat COPD and asthma patients. Advanced stepwise therapies for ACOS patients are based on patient characteristics and biomarkers. Very few clinical trials exist that focus specifically on ACOS patients.Expert opinion: After inhalers, advanced therapies including phosphodiesterase inhibitors, macrolides, N-acetylcysteine and statin therapy for those ACOS patients with a COPD appearance and exacerbations are available. In atopic ACOS patients with exacerbations, advanced asthma therapies (leukotriene receptor antagonists and synthesis blocking agents.) are used. ACOS patients with elevated blood eosinophil/IgE levels are considered for immunotherapy or therapeutic monoclonal antibodies blocking specific Th2/Type-2 interleukins or IgE. Symptom control, stabilization/improvement in pulmonary function and reduced exacerbations are the metrics of success. More pharmacological trials of ACOS patients are needed to better understand which patients benefit from specific treatments.Abbreviations: 5-LOi: 5-lipoxygenase inhibitor; ACOS: asthma - COPD overlap syndrome; B2AR: Beta2 adrenergic receptors; cAMP: cyclic adenosine monophosphate; cGMP: cyclic guanosine monophosphate; CI: confidence interval; COPD: chronic obstructive pulmonary disease; CRS : chronic rhinosinusitis; cys-LT: cysteinyl leukotrienes; DPI: dry powder inhaler; EMA: European Medicines Agency; FDA: US Food and Drug Administration; FDC: fixed-dose combination; FeNO: exhaled nitric oxide; FEV1: forced expiratory volume in one second; FVC: forced vital capacity; GM-CSF: granulocyte-macrophage colony-stimulating factor; ICS : inhaled corticosteroids; IL: interleukin; ILC2: Type 2 innate lymphoid cells; IP3: Inositol triphosphate; IRR: incidence rate ratio; KOLD: Korean Obstructive Lung Disease; LABA: long-acting B2 adrenergic receptor agonist; LAMA: long-acting muscarinic receptor antagonist; LRA: leukotriene receptor antagonist; LT: leukotrienes; MDI: metered-dose inhalers; MN: M-subtype muscarinic receptors; MRA: muscarinic receptor antagonist; NAC: N-acetylcysteine; NEB: nebulization; OR: odds ratio; PDE: phosphodiesterase; PEFR: peak expiratory flow rate; PGD2: prostaglandin D2; PRN: as needed; RR: risk ratio; SABA: short-acting B2 adrenergic receptor agonist; SAMA: short-acting muscarinic receptor antagonist; SDMI: spring-driven mist inhaler; Th1: T helper cell 1 lymphocyte; Th2: T helper cell 2 lymphocytes; TNF-α: tumor necrosis factor alpha; US : United States.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Skyler J Pearson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Susan Murin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
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9
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Nakamoto K, Watanabe M, Sada M, Inui T, Nakamura M, Honda K, Wada H, Ishii H, Takizawa H. Pseudomonas aeruginosa-derived flagellin stimulates IL-6 and IL-8 production in human bronchial epithelial cells: A potential mechanism for progression and exacerbation of COPD. Exp Lung Res 2019; 45:255-266. [PMID: 31517562 DOI: 10.1080/01902148.2019.1665147] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background and purpose of the study: Pseudomonas aeruginosa commonly colonizes the airway of patients with chronic obstructive pulmonary disease (COPD) and exacerbates their symptoms. P. aeruginosa carries flagellin that stimulates toll-like receptor (TLR)-5; however, the role of flagellin in the pathogenesis of COPD remains unclear. The aim of the study was to evaluate the mechanisms of the flagellin-induced innate immune response in bronchial epithelial cells, and to assess the effects of anti-inflammatory agents for treatment. Materials and methods: We stimulated BEAS-2B cells with P. aeruginosa-derived flagellin, and assessed mRNA expression and protein secretion of interleukin (IL)-6 and IL-8. We also used mitogen-activated protein kinases (MAPK) inhibitors to assess the signaling pathways involved in flagellin stimulation, and investigated the effect of clinically available anti-inflammatory agents against flagellin-induced inflammation. Results: Flagellin promoted protein and mRNA expression of IL-6 and IL-8 in BEAS-2B cells and induced phosphorylation of p38, ERK, and JNK; p38 phosphorylation-induced IL-6 production, while IL-8 production resulted from p38 and ERK phosphorylation. Fluticasone propionate (FP) and dexamethasone (DEX) suppressed IL-6 and IL-8 production in BEAS-2B cells, but clarithromycin (CAM) failed to do so. Conclusions: P. aeruginosa-derived flagellin-induced IL-6 and IL-8 production in bronchial epithelial cells, which partially explains the mechanisms of progression and exacerbation of COPD. Corticosteroids are the most effective treatment for the suppression of flagellin-induced IL-6 and IL-8 production in the bronchial epithelial cells.
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Affiliation(s)
- Keitaro Nakamoto
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Masato Watanabe
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Mitsuru Sada
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Toshiya Inui
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Masuo Nakamura
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Kojiro Honda
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Hiroo Wada
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Haruyuki Ishii
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
| | - Hajime Takizawa
- Department of Respiratory Medicine, Kyorin University School of Medicine , Tokyo , Japan
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10
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Singh D, D'Urzo AD, Donohue JF, Kerwin EM. Weighing the evidence for pharmacological treatment interventions in mild COPD; a narrative perspective. Respir Res 2019; 20:141. [PMID: 31286970 PMCID: PMC6615221 DOI: 10.1186/s12931-019-1108-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/24/2019] [Indexed: 12/15/2022] Open
Abstract
There is increasing focus on understanding the nature of chronic obstructive pulmonary disease (COPD) during the earlier stages. Mild COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 1 or the now-withdrawn GOLD stage 0) represents an early stage of COPD that may progress to more severe disease. This review summarises the disease burden of patients with mild COPD and discusses the evidence for treatment intervention in this subgroup. Overall, patients with mild COPD suffer a substantial disease burden that includes persistent or potentially debilitating symptoms, increased risk of exacerbations, increased healthcare utilisation, reduced exercise tolerance and physical activity, and a higher rate of lung function decline versus controls. However, the evidence for treatment efficacy in these patients is limited due to their frequent exclusion from clinical trials. Careful assessment of disease burden and the rate of disease progression in individual patients, rather than a reliance on spirometry data, may identify patients who could benefit from earlier treatment intervention.
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Affiliation(s)
- Dave Singh
- University of Manchester, Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, M23 9QZ, UK.
| | - Anthony D D'Urzo
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - James F Donohue
- Division of Pulmonary Diseases & Critical Care Medicine, University of North Carolina Pulmonary Critical Medicine, Chapel Hill, North Carolina, USA
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11
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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.
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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
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12
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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
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13
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Vanfleteren L, Fabbri LM, Papi A, Petruzzelli S, Celli B. Triple therapy (ICS/LABA/LAMA) in COPD: time for a reappraisal. Int J Chron Obstruct Pulmon Dis 2018; 13:3971-3981. [PMID: 30587953 PMCID: PMC6296179 DOI: 10.2147/copd.s185975] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Recently, two "fixed triple" single-inhaler combinations of an inhaled corticosteroid (ICS), a long-acting β2-agonist (LABA), and a long-acting muscarinic antagonist (LAMA) have become available for patients with COPD. This review presents the clinical evidence that led to the approval of these triple therapies, discusses the role of ICS in patients with COPD, and presents data on the relative efficacy of "fixed triple" (ICS/LAMA/LABA) therapy vs LAMA, ICS/LABA, and LAMA/LABA combinations, and summarizes studies in which ICS/LABAs were combined with LAMAs to form "open triple" combinations. Of the five main fixed triple studies completed so far, three evaluated the efficacy and safety of an extrafine formulation of beclometasone dipropionate, formoterol fumarate, and glycopyrronium; the other two studies evaluated fluticasone furoate, vilanterol, and umeclidinium. Overall, compared to LAMA, ICS/LABA, or LAMA/LABA, triple therapy decreased the risk of exacerbations and improved lung function and health status, with a favorable benefit-to-harm ratio. Furthermore, triple therapy showed a promising signal in terms of improved survival. The evidence suggests that triple therapy is the most effective treatment in moderate/severe symptomatic patients with COPD at risk of exacerbations, with marginal if any risk of side effects including pneumonia. Ongoing studies are examining the role of triple therapy in less severe symptomatic patients with COPD and asthma-COPD overlap.
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Affiliation(s)
- Lowie Vanfleteren
- COPD Center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden, .,CIRO, Horn, the Netherlands, .,Department of Respiratory Medicine, Maastricht University Medical Hospital, Maastricht, the Netherlands,
| | - Leonardo M Fabbri
- COPD Center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden, .,Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Bartolome Celli
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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14
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Pharmacological Therapy of COPD. Chest 2018; 154:1404-1415. [DOI: 10.1016/j.chest.2018.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/20/2022] Open
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15
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What have we learned from observational studies and clinical trials of mild to moderate COPD? Respir Res 2018; 19:177. [PMID: 30223834 PMCID: PMC6142698 DOI: 10.1186/s12931-018-0882-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 09/05/2018] [Indexed: 11/15/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. It is well established that patients with mild to moderate disease represent the majority of patients with COPD, and patients with mild COPD already have measurable physiological impairment with increased morbidity and a higher risk of mortality compared with healthy non-smoking individuals. However, this subpopulation is both underdiagnosed and undertreated. In addition, most clinical trials include cohorts of patients with worse lung function and quality of life, which are very different from the milder patients usually seen in primary care. Clinical trials have shown that mild-moderate COPD patients present an improvement in lung function after treatment with long-acting bronchodilators (LABD). Inhaled therapy has also shown benefits in terms of symptoms, health-related quality of life (HRQL) and exacerbation prevention in this population. Early intervention might have also a positive effect to prevent functional impairment. Nevertheless, there is scarce evidence from randomised clinical trials and real-life studies about the importance of pharmacological treatment in early stages of COPD to improve long-term outcomes. New concepts such as clinically important deterioration may help to investigate the impact of interventions on the natural history of the disease.
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16
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Di Marco F, Santus P, Terraneo S, Peruzzi E, Muscianisi E, Ripellino C, Pegoraro V. Characteristics of newly diagnosed COPD patients treated with triple inhaled therapy by general practitioners: a real world Italian study. NPJ Prim Care Respir Med 2017; 27:51. [PMID: 28883469 PMCID: PMC5589801 DOI: 10.1038/s41533-017-0051-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 06/15/2017] [Accepted: 07/24/2017] [Indexed: 12/02/2022] Open
Abstract
Factors predicting prescriptions of triple therapy were investigated in a large group of general practitioners in Italy. In the population treated by identified general practitioners, a cohort of newly diagnosed chronic obstructive pulmonary disease patients was extracted from IMS Health Longitudinal Database during the period 2010-2013. From the diagnosis, 1-year follow-up was evaluated. Thirty-two thousand forty-six newly diagnosed chronic obstructive pulmonary disease patients were evaluated (57.7% male, mean age 67 years). During 2 years prior to diagnosis less than 13% of patients were requested with a pulmonology evaluation and less than 5% with a spirometry; 65.1% cases were prescribed with a respiratory drug, which in 9.6% of cases was inhaled corticosteroid/long-acting β2-agonist fixed-dose combination. Two thousand and twenty eight patients (6.3% of the newly diagnosed chronic obstructive pulmonary disease patients) were treated with triple therapy during the first year of follow-up, whose 858 (42.3%) starting immediately, and 762 (37.6%) following an initial treatment with inhaled corticosteroid/long-acting β2-agonist fixed-dose combination. Being older, being requested with pulmonologist evaluation or spirometry, being prescribed with a inhaled corticosteroid/long-acting β2-agonist fixed-dose combination at diagnosis resulted independent predictors of triple therapy use. CHRONIC LUNG DISEASE ENSURING CORRECT PRESCRIPTIONS FOR EARLY-STAGE DISEASE: An improved education program for doctors promoting correct use of medication for chronic lung disease is needed in Italy. Current guidelines state that inhaled corticosteroids (ICSs) should be reserved for patients with severe chronic obstructive pulmonary disease (COPD), but it appears that doctors do not always follow this advice. Fabiano Di Marco, at San Paolo Hospital-Università degli Studi di Milano, and co-workers analyzed data from 32,046 COPD patients newly-diagnosed by family doctors in Italy between 2010 and 2013. When the researchers followed up on patients after 1 year, 2028 (6.3%) of newly-diagnosed patients were being treated with triple inhaled therapy incorporating ICSs-42% of these patients had started triple therapy immediately upon diagnosis. Being an older male and having been prescribed with a ICS/LABA FDC at diagnosis were strong predictors of triple therapy use within 1 year from the diagnosis.
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Affiliation(s)
- Fabiano Di Marco
- Department of Medical Sciences, Università degli Studi di Milano. Respiratory Unit, San Paolo Hospital, Milan, Italy
| | - Pierachille Santus
- Department of Medical Sciences, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, Scientific Institute of Milan-IRCCS, Milan, Italy
| | - Silvia Terraneo
- Department of Medical Sciences, Università degli Studi di Milano. Respiratory Unit, San Paolo Hospital, Milan, Italy
| | - Elena Peruzzi
- Epidemiology and Outcome Research Manager, Novartis Italia, Origgio, VA, Italy
| | - Elisa Muscianisi
- Medical Franchise Leader Respiratory, Novartis Italia, Origgio, VA, Italy
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17
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Perng DW, Chen PK. The Relationship between Airway Inflammation and Exacerbation in Chronic Obstructive Pulmonary Disease. Tuberc Respir Dis (Seoul) 2017; 80:325-335. [PMID: 28905537 PMCID: PMC5617848 DOI: 10.4046/trd.2017.0085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 07/28/2017] [Accepted: 07/31/2017] [Indexed: 01/11/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with abnormal inflammatory response and airflow limitation. Acute exacerbation involves increased inflammatory burden leading to worsening respiratory symptoms, including dyspnea and sputum production. Some COPD patients have frequent exacerbations (two or more exacerbations per year). A substantial proportion of COPD patients may remain stable without exacerbation. Bacterial and viral infections are the most common causative factors that breach airway stability and lead to exacerbation. The increasing prevalence of exacerbation is associated with deteriorating lung function, hospitalization, and risk of death. In this review, we summarize the mechanisms of airway inflammation in COPD and discuss how bacterial or viral infection, temperature, air pollution, eosinophilic inflammation, and concomitant chronic diseases increase airway inflammation and the risk of exacerbation.
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Affiliation(s)
- Diahn Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Pei Ku Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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18
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Cheng SL, Wang HH, Lin CH. Effect of allergic phenotype on treatment response to inhaled bronchodilators with or without inhaled corticosteroids in patients with COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:2231-2238. [PMID: 28814851 PMCID: PMC5546185 DOI: 10.2147/copd.s140748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a heterogeneous disorder encompassing different phenotypes with different responses to treatment. The present 1-year, two-center hospital-based study investigated whether the plasma immunoglobulin E (IgE) level and/or eosinophil cell count could be used as biomarkers to stratify patients with COPD according to predicted responses to inhaled corticosteroids (ICS)-based therapy. METHODS A hospital-data based cohort study of COPD patients treated at two territory hospital centers was conducted for 1 year. Allergic biomarkers, including blood eosinophil counts and IgE levels, were assessed at baseline. Lung function parameters, including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and the COPD Assessment Test (CAT), were also evaluated. The frequencies of acute exacerbation (AE) and pneumonia were also measured. Eosinophilia and a high IgE level were defined as >3% and 173 IU/mL, respectively. RESULTS A total of 304 patients were included. Among patients with eosinophilia and high IgE levels, ICS-based therapy was associated with significant improvements in FEV1, FVC, and CAT scores, compared with bronchodilator (BD) therapy (P≤0.042). ICS-based therapy was also associated with a significantly lower incidence of AE vs BD-based therapy (11.7% vs 24.1%; P<0.008). Among patients with only eosinophilia, ICS-based therapy yielded significantly better CAT score results vs BD-based treatment (7 vs 13; P=0.032). A receiver operating characteristic curve analysis found that the combination of a high plasma IgE level and eosinophilia most sensitively and specifically identified patients who would benefit from the addition of ICS to BD therapy. CONCLUSION Our findings support the use of blood eosinophil cell counts plus IgE levels as predictive biomarkers of the ICS response in certain patients with COPD. Both biomarkers could potentially be used to stratify COPD patients regarding ICS-based therapy.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei
- Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan
| | - Hsu Hui Wang
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei
| | - Ching-Hsiung Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua
- Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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19
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Takayanagi S, Kawata N, Tada Y, Ikari J, Matsuura Y, Matsuoka S, Matsushita S, Yanagawa N, Kasahara Y, Tatsumi K. Longitudinal changes in structural abnormalities using MDCT in COPD: do the CT measurements of airway wall thickness and small pulmonary vessels change in parallel with emphysematous progression? Int J Chron Obstruct Pulmon Dis 2017; 12:551-560. [PMID: 28243075 PMCID: PMC5315203 DOI: 10.2147/copd.s121405] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Recent advances in multidetector computed tomography (MDCT) facilitate acquiring important clinical information for managing patients with COPD. MDCT can detect the loss of lung tissue associated with emphysema as a low-attenuation area (LAA) and the thickness of airways as the wall area percentage (WA%). The percentage of small pulmonary vessels <5 mm2 (% cross-sectional area [CSA] <5) has been recently recognized as a parameter for expressing pulmonary perfusion. We aimed to analyze the longitudinal changes in structural abnormalities using these CT parameters and analyze the effect of exacerbation and smoking cessation on structural changes in COPD patients. Methods We performed pulmonary function tests (PFTs), an MDCT, and a COPD assessment test (CAT) in 58 patients with COPD at the time of their enrollment at the hospital and 2 years later. We analyzed the change in clinical parameters including CT indices and examined the effect of exacerbations and smoking cessation on the structural changes. Results The CAT score and forced expiratory volume in 1 second (FEV1) did not significantly change during the follow-up period. The parameters of emphysematous changes significantly increased. On the other hand, the WA% at the distal airways significantly decreased or tended to decrease, and the %CSA <5 slightly but significantly increased over the same period, especially in ex-smokers. The parameters of emphysematous change were greater in patients with exacerbations and continued to progress even after smoking cessation. In contrast, the WA% and %CSA <5 did not change in proportion to emphysema progression. Conclusion The WA% at the distal bronchi and the %CSA <5 did not change in parallel with parameters of LAA over the same period. We propose that airway disease and vascular remodeling may be reversible to some extent by smoking cessation and appropriate treatment. Optimal management may have a greater effect on pulmonary vascularity and airway disease than parenchymal deconstruction in the early stage of COPD.
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Affiliation(s)
- Shin Takayanagi
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
| | - Naoko Kawata
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
| | - Yuji Tada
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
| | - Jun Ikari
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
| | - Yukiko Matsuura
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
| | - Shin Matsuoka
- Department of Radiology, St Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, Japan
| | - Shoichiro Matsushita
- Department of Radiology, St Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, Japan
| | - Noriyuki Yanagawa
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
| | - Yasunori Kasahara
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba-shi, Chiba
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20
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Andreeva-Gateva PA, Stamenova E, Gatev T. The place of inhaled corticosteroids in the treatment of chronic obstructive pulmonary disease: a narrative review. Postgrad Med 2017; 128:474-84. [PMID: 27153510 DOI: 10.1080/00325481.2016.1186487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Inhaled corticosteroids (ICSs) belong to the armament for treatment of chronic obstructive pulmonary disease (COPD) and as such, they are widely used in real life. This is a narrative review on evidence-based papers published in the English language listed in Medline between 1990 and March 2016 discussing ICS application in COPD. Recent meta-analyses clearly show that ICSs are able to decrease the rate of exacerbation and to delay the decline of lung function, although they do not prolong life, nor stop the progression of the disease. ICSs are included in guidelines for COPD treatment, exclusively in combination with bronch-15 odilators. However, adverse effects as pneumonia, cataracts, osteoporosis, etc. seem obvious. Newer studies show that patients with COPD are not a homogeneous population, and recently several phenotypes were identified, including asthma-COPD overlap syndrome (ACOS), among others. The efficacy of ICSs seems to be unequal for different subpopulations of patients with COPD and further research is needed to address a personalized approach in the treatment of COPD patients, and to 20 identify predictors for ICS treatment success. Usage of ICSs in patients with COPD needs to be précised especially in patients with COPD without asthma.
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Affiliation(s)
- Pavlina A Andreeva-Gateva
- a Faculty of Medicine, Department of Pharmacology and Toxicology , Medical University - Sofia , Sofia , Bulgaria.,b Faculty of Medicine, Department of Internal Diseases, Pharmacology and Clinical Pharmacology, Pediatrics, Epidemiology, Infectious Diseases, and Skin Diseases , Sofia University 'St. Kliment Ohridski' , Sofia , Bulgaria
| | - Eleonora Stamenova
- b Faculty of Medicine, Department of Internal Diseases, Pharmacology and Clinical Pharmacology, Pediatrics, Epidemiology, Infectious Diseases, and Skin Diseases , Sofia University 'St. Kliment Ohridski' , Sofia , Bulgaria
| | - Tzvetelin Gatev
- c Department of Forensic Medicine , Military Hospital , Sofia , Bulgaria
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21
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Lee SY, Park HY, Kim EK, Lim SY, Rhee CK, Hwang YI, Oh YM, Lee SD, Park YB. Combination therapy of inhaled steroids and long-acting beta2-agonists in asthma-COPD overlap syndrome. Int J Chron Obstruct Pulmon Dis 2016; 11:2797-2803. [PMID: 27877033 PMCID: PMC5108502 DOI: 10.2147/copd.s114964] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The efficacy of inhaled corticosteroids (ICSs)/long-acting beta2-agonist (LABA) treatment in patients with asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) compared to patients with COPD alone has rarely been examined. This study aimed to evaluate the clinical efficacy for the improvement of lung function after ICS/LABA treatment in patients with ACOS compared to COPD alone patients. METHODS Patients with stable COPD were selected from the Korean Obstructive Lung Disease (KOLD) cohort. Subjects began a 3-month ICS/LABA treatment after a washout period. ACOS was defined when the patients had 1) a personal history of asthma, irrespective of age, and wheezing in the last 12 months in a self-reported survey and 2) a positive bronchodilator response. RESULTS Among 152 eligible COPD patients, 45 (29.6%) fulfilled the criteria for ACOS. After a 3-month treatment with ICS/LABA, the increase in forced expiratory volume in 1 second (FEV1) was significantly greater in ACOS patients than in those with COPD alone (240.2±33.5 vs 124.6±19.8 mL, P=0.002). This increase in FEV1 persisted even after adjustment for confounding factors (adjusted P=0.002). According to severity of baseline FEV1, the ACOS group showed a significantly greater increase in FEV1 than the COPD-alone group in patients with mild-to-moderate airflow limitation (223.2±42.9 vs 84.6±25.3 mL, P=0.005), whereas there was no statistically significant difference in patients with severe to very severe airflow limitation. CONCLUSION This study provides clinical evidence that ACOS patients with mild-to-moderate airflow limitation showed a greater response in lung function after 3 months of ICS/LABA combination treatment.
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Affiliation(s)
- Suh-Young Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Eun Kyung Kim
- Department of Internal Medicine, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam
| | - Seong Yong Lim
- Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Chin Kook Rhee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Yong Il Hwang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical School, Gyeonggido
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Sang Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Yong Bum Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine
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22
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Price DB, Russell R, Mares R, Burden A, Skinner D, Mikkelsen H, Ding C, Brice R, Chavannes NH, Kocks JWH, Stephens JW, Haughney J. Metabolic Effects Associated with ICS in Patients with COPD and Comorbid Type 2 Diabetes: A Historical Matched Cohort Study. PLoS One 2016; 11:e0162903. [PMID: 27658209 PMCID: PMC5033451 DOI: 10.1371/journal.pone.0162903] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 08/30/2016] [Indexed: 12/24/2022] Open
Abstract
Background Management guidelines for chronic obstructive pulmonary disease (COPD) recommend that inhaled corticosteroids (ICS) are prescribed to patients with the most severe symptoms. However, these guidelines have not been widely implemented by physicians, leading to widespread use of ICS in patients with mild-to-moderate COPD. Of particular concern is the potential risk of worsening diabetic control associated with ICS use. Here we investigate whether ICS therapy in patients with COPD and comorbid type 2 diabetes mellitus (T2DM) has a negative impact on diabetic control, and whether these negative effects are dose-dependent. Methods and Findings This was a historical matched cohort study utilising primary care medical record data from two large UK databases. We selected patients aged ≥40 years with COPD and T2DM, prescribed ICS (n = 1360) or non-ICS therapy (n = 2642) between 2008 and 2012. The primary endpoint was change in HbA1c between the baseline and outcome periods. After 1:1 matching, each cohort consisted of 682 patients. Over the 12–18-month outcome period, patients prescribed ICS had significantly greater increases in HbA1c values compared with those prescribed non-ICS therapies; adjusted difference 0.16% (95% confidence interval [CI]: 0.05–0.27%) in all COPD patients, and 0.25% (95% CI: 0.10–0.40%) in mild-to-moderate COPD patients. Patients in the ICS cohort also had significantly more diabetes-related general practice visits per year and received more frequent glucose strip prescriptions, compared with those prescribed non-ICS therapies. Patients prescribed higher cumulative doses of ICS (>250 mg) had greater odds of increased HbA1c and/or receiving additional antidiabetic medication, and increased odds of being above the Quality and Outcomes Framework (QOF) target for HbA1c levels, compared with those prescribed lower cumulative doses (≤125 mg). Conclusion For patients with COPD and comorbid T2DM, ICS therapy may have a negative impact on diabetes control. Patients prescribed higher cumulative doses of ICS may be at greater risk of diabetes progression. Trial Registration ENCePP ENCEPP/SDPP/6804
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Affiliation(s)
- David B. Price
- Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
- Observational and Pragmatic Research Institute, Singapore, Singapore
- * E-mail:
| | - Richard Russell
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rafael Mares
- Research in Real Life Ltd, Cambridge, United Kingdom
| | - Anne Burden
- Cambridge Research Support, Cambridge, United Kingdom
| | | | | | - Cherlyn Ding
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Richard Brice
- Whitstable Medical Practice, Whitstable, Canterbury, United Kingdom
| | - Niels H. Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Janwillem W. H. Kocks
- Department of General Practice and GRIAC Research Institute, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeffrey W. Stephens
- Diabetes Research Group, Institute of Life Sciences, Swansea University, Swansea, United Kingdom
| | - John Haughney
- Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
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Liu SF, Kuo HC, Liu GH, Ho SC, Chang HC, Huang HT, Chen YM, Huang KT, Chen KY, Fang WF, Lin MC. Inhaled corticosteroids can reduce osteoporosis in female patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:1607-14. [PMID: 27478374 PMCID: PMC4951067 DOI: 10.2147/copd.s106054] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Whether the use of inhaled corticosteroids (ICSs) in patients with COPD can protect from osteoporosis remains undetermined. The aim of this study is to assess the incidence of osteoporosis in patients with COPD with ICS use and without. Patients and methods This is a retrospective cohort and population-based study in which we extracted newly diagnosed female patients with COPD between 1997 and 2009 from Taiwan’s National Health Insurance (TNHI) database between 1996 and 2011 (International Classification of Diseases, Ninth Revision – Clinical Modification [ICD-9-CM] 491, 492, 496). The patients with COPD were defined by the presence of two or more diagnostic codes for COPD within 12 months on either inpatient or outpatient service claims submitted to TNHI. Patients were excluded if they were younger than 40 years or if osteoporosis had been diagnosed prior to the diagnosis of COPD and cases of asthma (ICD-9 CM code 493.X) before the index date. These enrolled patients were followed up till 2011, and the incidence of osteoporosis was determined. The Cox proportional hazards regression model was also used to estimate hazard ratios (HRs) for incidences of lung cancer. Results Totally, 10,723 patients with COPD, including ICS users (n=812) and nonusers (n=9,911), were enrolled. The incidence rate of osteoporosis per 100,000 person years is 4,395 in nonusers and 2,709 in ICS users (HR: 0.73, 95% confidence interval [CI]: 0.63–084). The higher ICS dose is associated with lower risk of osteoporosis (0 mg to ≤20 mg, HR: 0.84, 95% CI: 0.69–1.04; >20 mg to ≤60 mg, HR: 0.78, 95% CI: 0.59–1.04; and >60 mg, HR: 0.72, 95% CI: 0.55–0.96; P for trend =0.0023) after adjusting for age, income, and medications. The cumulative osteoporosis probability significantly decreased among the ICS users when compared with the nonusers (P<0.001). Conclusion Female patients with COPD using ICS have a dose–response protective effect for osteoporosis.
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Affiliation(s)
- Shih-Feng Liu
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine
| | - Ho-Chang Kuo
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital
| | | | - Shu-Chen Ho
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital
| | - Huang-Chih Chang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Chang Gung University College of Medicine
| | - Hung-Tu Huang
- Department of Anatomy, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China
| | - Yu-Mu Chen
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
| | - Kuo-Tung Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Chang Gung University College of Medicine
| | - Kuan-Yi Chen
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital
| | - Wen-Feng Fang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine
| | - Meng-Chih Lin
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine
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Burchette JE, Campbell GD, Geraci SA. Preventing Hospitalizations From Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Med Sci 2016; 353:31-40. [PMID: 28104101 DOI: 10.1016/j.amjms.2016.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/27/2016] [Accepted: 06/09/2016] [Indexed: 01/01/2023]
Abstract
Chronic obstructive lung disease is among the leading causes of adult hospital admissions and readmissions in the United States. Preventing acute exacerbations is the primary approach in therapy. Combinations of smoking cessation, pulmonary rehabilitation, vaccinations and inhaled and oral medications may all reduce the overall risk of acute exacerbations. When prevention is unsuccessful, treatment of exacerbations often does not require hospitalization but can be safely executed in the outpatient setting. In the patient who does not require mechanical ventilation or who manifests respiratory acidosis, oxygen supplementation, frequent short-acting inhaled bronchodilators, oral corticosteroids and often antibiotics can abort the decompensation and sometimes return the patient to his or her pre-attack baseline lung function. Several models exist for delivering this care in the ambulatory setting. Follow-up care after an exacerbation has resolved is important, though there are few hard data suggesting which approach is best in this setting.
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Affiliation(s)
- Jessica E Burchette
- Department of Pharmacy Practice, Gatton College of Pharmacy, East Tennessee State University, Johnson City, Tennessee.
| | - G Douglas Campbell
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Mississippi School of Medicine, Jackson, Mississippi; G.V. (Sonny) Montgomery Veterans Affairs Medical Center, Jackson, Mississippi
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25
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Takeda Y, Suzuki M, Jin Y, Tachibana I. Preventive Role of Tetraspanin CD9 in Systemic Inflammation of Chronic Obstructive Pulmonary Disease. Am J Respir Cell Mol Biol 2016; 53:751-60. [PMID: 26378766 DOI: 10.1165/rcmb.2015-0122tr] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is frequently associated with extrapulmonary complications, including cardiovascular disease, diabetes, and osteoporosis. Persistent, low-grade, systemic inflammation underlies these comorbid disorders. Tetraspanins, which have a characteristic structure spanning the membrane four times, facilitate lateral organization of molecular complexes and thereby form tetraspanin-enriched microdomains that are distinct from lipid rafts. Recent basic research has suggested a preventive role of tetraspanin CD9 in COPD. CD9-enriched microdomains negatively regulate LPS-induced receptor formation by preventing CD14 from accumulating into the rafts, and decreased CD9 in macrophages enhances inflammation in mice. Mice doubly deficient in CD9 and a related tetraspanin, CD81, show pulmonary emphysema, weight loss, and osteopenia, a phenotype akin to human COPD. A therapeutic approach to up-regulating CD9 in macrophages might improve the clinical course of patients with COPD with comorbidities.
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Affiliation(s)
- Yoshito Takeda
- 1 Department of Respiratory Medicine, Allergy, and Rheumatic Diseases, Osaka University Graduate School of Medicine, Suita, Osaka, Japan, and
| | - Mayumi Suzuki
- 2 Department of Medicine, Nissay Hospital, Nippon Life Saiseikai Public Interest Incorporated Foundation, Nishi-ku, Osaka, Japan
| | - Yingji Jin
- 1 Department of Respiratory Medicine, Allergy, and Rheumatic Diseases, Osaka University Graduate School of Medicine, Suita, Osaka, Japan, and
| | - Isao Tachibana
- 2 Department of Medicine, Nissay Hospital, Nippon Life Saiseikai Public Interest Incorporated Foundation, Nishi-ku, Osaka, Japan
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Brusselle G, Price D, Gruffydd-Jones K, Miravitlles M, Keininger DL, Stewart R, Baldwin M, Jones RC. The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK. Int J Chron Obstruct Pulmon Dis 2015; 10:2207-17. [PMID: 26527869 PMCID: PMC4621207 DOI: 10.2147/copd.s91694] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [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
BACKGROUND Real-world prescription pathways leading to triple therapy (TT) (inhaled corticosteroid [ICS] plus long-acting β2-agonist bronchodilator [LABA] plus long-acting muscarinic antagonist) differ from Global initiative for chronic Obstructive Lung Disease [GOLD] and National Institute for Health and Care Excellence treatment recommendations. This study sets out to identify COPD patients without asthma receiving TT, and determine the pathways taken from diagnosis to the first prescription of TT. METHODS This was a historical analysis of COPD patients without asthma from the Optimum Patient Care Research Database (387 primary-care practices across the UK) from 2002 to 2010. Patient disease severity was classified using GOLD 2013 criteria. Data were analyzed to determine prescribing of TT before, at, and after COPD diagnosis; the average time taken to receive TT; and the impact of lung function grade, modified Medical Research Council dyspnea score, and exacerbation history on the pathway to TT. RESULTS During the study period, 32% of patients received TT. Of these, 19%, 28%, 37%, and 46% of patients classified as GOLD A, B, C, and D, respectively, progressed to TT after diagnosis (P<0.001). Of all patients prescribed TT, 25% were prescribed TT within 1 year of diagnosis, irrespective of GOLD classification (P=0.065). The most common prescription pathway to TT was LABA plus ICS. It was observed that exacerbation history did influence the pathway of LABA plus ICS to TT. CONCLUSION Real life UK prescription data demonstrates the inappropriate prescribing of TT and confirms that starting patients on ICS plus LABA results in the inevitable drift to overuse of TT. This study highlights the need for dissemination and implementation of COPD guidelines to physicians, ensuring that patients receive the recommended therapy.
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Affiliation(s)
- Guy Brusselle
- Department of Respiratory Medicine, University Hospital Ghent, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
- Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Research in Real Life (RiRL), Singapore
| | | | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | | | | | - Rupert C Jones
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
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27
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Takahashi S, Betsuyaku T. The chronic obstructive pulmonary disease comorbidity spectrum in Japan differs from that in western countries. Respir Investig 2015; 53:259-70. [PMID: 26521103 DOI: 10.1016/j.resinv.2015.05.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 05/14/2015] [Accepted: 05/18/2015] [Indexed: 01/11/2023]
Abstract
Patients with Chronic Obstructive Pulmonary Disease (COPD) frequently suffer from various comorbidities, such as cardiovascular disease, osteoporosis, depression, malnutrition, metabolic syndrome, diabetes, and lung cancer. These comorbidities have a significant impact on disease severity and survival. In fact, guidelines from both the Global Initiative for Chronic Obstructive Lung Disease and the Japanese Respiratory Society recommend that physicians take comorbidities into account when they evaluate COPD severity. These guidelines also emphasize the importance of managing comorbidities alongside airway obstruction in COPD. The mechanisms by which the many COPD-related comorbidities develop are still unclear. Aging and smoking are well-established as major factors. However, systemic inflammation may also contribute to the disease process. Having developed from the classical theory to differentiate COPD patients into "pink puffers" and "blue bloaters", COPD is now generally considered as a heterogeneous condition. On this point, we have noticed that the characteristics of Japanese COPD patients tend to differ from those of Westerners. Specifically, Japanese patients tend to be older, to have lower body mass index, to suffer from emphysema-dominant lung disease, and to experience exacerbations less frequently. The comorbidity spectrum of Japanese COPD patients also seems to differ from that of Westerners. For instance, in Japanese patients, cardiovascular disease and metabolic syndrome are less prevalent, whereas osteoporosis and malnutrition are more frequent. In order to treat Japanese COPD patients optimally, we must pay particular attention to their unique demographics and comorbidity spectrum, which contrast with those of Western COPD patients.
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Affiliation(s)
- Saeko Takahashi
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tomoko Betsuyaku
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.
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28
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Bujarski S, Parulekar AD, Sharafkhaneh A, Hanania NA. The asthma COPD overlap syndrome (ACOS). Curr Allergy Asthma Rep 2015; 15:509. [PMID: 25712010 DOI: 10.1007/s11882-014-0509-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) have traditionally been viewed as distinct clinical entities. Recently, however, much attention has been focused on patients with overlapping features of both asthma and COPD: those with asthma COPD overlap syndrome (ACOS). Although no universal definition criteria exist, recent publications attempted to define patients with ACOS based on differences in clinical features, radiographic findings, and diagnostic tests. Patients with ACOS make up a large percentage of those with obstructive lung disease and have a higher overall health-care burden. Identifying patients with ACOS has significant therapeutic implications particularly with the need for early use of inhaled corticosteroids and the avoidance of use of long-acting bronchodilators alone in such patients. However, unlike asthma and COPD, no evidence-based guidelines for the management of ACOS currently exist. Future research is needed to improve our understanding of ACOS and to achieve the best management strategies.
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Affiliation(s)
- Stephen Bujarski
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX, 77030, USA,
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29
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Zhong N, Wang C, Zhou X, Zhang N, Humphries M, Wang L, Thach C, Patalano F, Banerji D. LANTERN: a randomized study of QVA149 versus salmeterol/fluticasone combination in patients with COPD. Int J Chron Obstruct Pulmon Dis 2015; 10:1015-26. [PMID: 26082625 PMCID: PMC4461092 DOI: 10.2147/copd.s84436] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The current Global initiative for chronic Obstructive Lung Disease (GOLD) treatment strategy recommends the use of one or more bronchodilators according to the patient's airflow limitation, their history of exacerbations, and symptoms. The LANTERN study evaluated the effect of the long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) dual bronchodilator, QVA149 (indacaterol/glycopyrronium), as compared with the LABA/inhaled corticosteroid, salmeterol/fluticasone (SFC), in patients with moderate-to-severe COPD with a history of ≤1 exacerbation in the previous year. METHODS In this double-blind, double-dummy, parallel-group study, 744 patients with moderate-to-severe COPD with a history of ≤1 exacerbations in the previous year were randomized (1:1) to QVA149 110/50 μg once daily or SFC 50/500 μg twice daily for 26 weeks. The primary endpoint was noninferiority of QVA149 versus SFC for trough forced expiratory volume in 1 second (FEV1) at week 26. RESULTS Overall, 676 patients completed the study. The primary objective of noninferiority between QVA149 and SFC in trough FEV1 at week 26 was met. QVA149 demonstrated statistically significant superiority to SFC for trough FEV1 (treatment difference [Δ]=75 mL; P<0.001). QVA149 demonstrated a statistically significant improvement in standardized area under the curve (AUC) from 0 hours to 4 hours for FEV1 (FEV1 AUC0-4h) at week 26 versus SFC (Δ=122 mL; P<0.001). QVA149 and SFC had similar improvements in transition dyspnea index focal score, St George Respiratory Questionnaire total score, and rescue medication use. However, QVA149 significantly reduced the rate of moderate or severe exacerbations by 31% (P=0.048) over SFC. Overall, the incidence of adverse events was comparable between QVA149 (40.1%) and SFC (47.4%). The incidence of pneumonia was threefold lower with QVA149 (0.8%) versus SFC (2.7%). CONCLUSION These findings support the use of the LABA/LAMA, QVA149 as an alternative treatment, over LABA/inhaled corticosteroid, in the management of moderate-to-severe COPD patients (GOLD B and GOLD D) with a history of ≤1 exacerbation in the previous year.
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Affiliation(s)
- Nanshan Zhong
- State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Changzheng Wang
- Institute of Respiratory Disease, Xin Qiao Hospital, Third Military Medical University, Chongqing City, Chongqing, People's Republic of China
| | - Xiangdong Zhou
- Department of Respiratory Medicine, Southwest Hospital, Third Military Medical University, Chongqing City, Chongqing, People's Republic of China
| | - Nuofu Zhang
- State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Michael Humphries
- Beijing Novartis Pharma Co. Ltd., Shanghai, People's Republic of China
| | - Linda Wang
- Beijing Novartis Pharma Co. Ltd., Shanghai, People's Republic of China
| | - Chau Thach
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Donald Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Criner GJ, Bourbeau J, Diekemper RL, Ouellette DR, Goodridge D, Hernandez P, Curren K, Balter MS, Bhutani M, Camp PG, Celli BR, Dechman G, Dransfield MT, Fiel SB, Foreman MG, Hanania NA, Ireland BK, Marchetti N, Marciniuk DD, Mularski RA, Ornelas J, Road JD, Stickland MK. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest 2015; 147:894-942. [PMID: 25321320 PMCID: PMC4388124 DOI: 10.1378/chest.14-1676] [Citation(s) in RCA: 182] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 09/17/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations. METHODS In recognition of the importance of preventing exacerbations in patients with COPD, the American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) joint evidence-based guideline (AECOPD Guideline) was developed to provide a practical, clinically useful document to describe the current state of knowledge regarding the prevention of acute exacerbations according to major categories of prevention therapies. Three key clinical questions developed using the PICO (population, intervention, comparator, and outcome) format addressed the prevention of acute exacerbations of COPD: nonpharmacologic therapies, inhaled therapies, and oral therapies. We used recognized document evaluation tools to assess and choose the most appropriate studies and to extract meaningful data and grade the level of evidence to support the recommendations in each PICO question in a balanced and unbiased fashion. RESULTS The AECOPD Guideline is unique not only for its topic, the prevention of acute exacerbations of COPD, but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD. CONCLUSIONS This guideline is unique because it provides an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data regarding the prevention of COPD exacerbations.
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Affiliation(s)
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | | | | | - Donna Goodridge
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kristen Curren
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | | | - Mohit Bhutani
- Division of Respirology, University of Toronto, Toronto, ON, Canada
| | - Pat G Camp
- University of Alberta, Edmonton, AB, Canada
| | - Bartolome R Celli
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Gail Dechman
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Mark T Dransfield
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL
| | | | | | | | | | | | - Darcy D Marciniuk
- Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | | | | | - Jeremy D Road
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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D'Urzo A, Donohue JF, Kardos P, Miravitlles M, Price D. A re-evaluation of the role of inhaled corticosteroids in the management of patients with chronic obstructive pulmonary disease. Expert Opin Pharmacother 2015; 16:1845-60. [PMID: 26194213 PMCID: PMC4673525 DOI: 10.1517/14656566.2015.1067682] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) (in fixed combinations with long-acting β2-agonists [LABAs]) are frequently prescribed for patients with chronic obstructive pulmonary disease (COPD), outside their labeled indications and recommended treatment strategies and guidelines, despite having the potential to cause significant side effects. AREAS COVERED Although the existence of asthma in patients with asthma-COPD overlap syndrome (ACOS) clearly supports the use of anti-inflammatory treatment (typically an ICS/LABA combination, as ICS monotherapy is usually not indicated for COPD), the current level of ICS/LABA use is not consistent with the prevalence of ACOS in the COPD population. Data have recently become available showing the comparative efficacy of fixed bronchodilator combinations (long-acting muscarinic antagonist [LAMA]/LABA with ICS/LABA combinations). Additionally, new information has emerged on ICS withdrawal without increased risk of exacerbations, under cover of effective bronchodilation. EXPERT OPINION For patients with COPD who do not have ACOS, a LAMA/LABA combination may be an appropriate starting therapy, apart from those with mild disease who can be managed with a single long-acting bronchodilator. Patients who remain symptomatic or present with exacerbations despite effectively delivered LAMA/LABA treatment may require additional drug therapy, such as ICS or phosphodiesterase-4 inhibitors. When prescribing an ICS/LABA, the risk:benefit ratio should be considered in individual patients.
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Affiliation(s)
- Anthony D'Urzo
- University of Toronto, Department of Family and Community Medicine , 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7 , Canada +1 416 652 9336 ; +1 416 652 0218 ;
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Montalbano AM, Albano GD, Anzalone G, Bonanno A, Riccobono L, Di Sano C, Gagliardo R, Siena L, Pieper MP, Gjomarkaj M, Profita M. Cigarette smoke alters non-neuronal cholinergic system components inducing MUC5AC production in the H292 cell line. Eur J Pharmacol 2014; 736:35-43. [PMID: 24797786 DOI: 10.1016/j.ejphar.2014.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/11/2014] [Accepted: 04/16/2014] [Indexed: 01/26/2023]
Abstract
Cigarette smoke extract (CSE) affects the expression of Choline Acetyl-Transferase (ChAT), muscarinic acetylcholine receptors, and mucin production in bronchial epithelial cells. Mucin 5AC (MUC5AC), muscarinic acetylcholine receptor M3, ChAT expression, acetylcholine levels and acetylcholine binding were measured in a human pulmonary mucoepidermoid carcinoma cell line (H292) stimulated with CSE. We performed ChAT/RNA interference experiments in H292 cells stimulated with CSE to study the role of ChAT/acetylcholine in MUC5AC production. The effects of Hemicholinium-3 (HCh-3) (50 μM) (a potent and selective choline uptake blocker) and Tiotropium bromide (Spiriva(®)) (100 nM), alone or in combination with Salmeterol (SL) and Fluticasone propionate (FP), were tested in this model. MUC5AC, muscarinic acetylcholine receptor M3, ChAT, acetylcholine expression and acetylcholine binding significantly increased in H292 cells stimulated with CSE (5%) compared to untreated cells. HCh-3 reduced acetylcholine binding and MUC5AC production in H292 cells stimulated with CSE. ChAT/RNA interference eliminated the effect of CSE on MUC5AC production. FP reduced ChAT and acetylcholine binding in unstimulated cells, while showing a partial effect in CSE stimulated cells. SL increased the ChAT expression and acetylcholine binding in H292 cells stimulated with or without CSE. Tiotropium, alone or together with FP and SL, reduced acetylcholine binding and MUC5AC production in H292 cells stimulated with CSE. CSE affects the ChAT/acetylcholine expression, increasing MUC5AC production in H292 cells. Pharmacological treatment with anticholinergic drugs reduces the secretion of MUC5AC generated by autocrine acetylcholine activity in airway epithelial cells.
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Affiliation(s)
- Angela Marina Montalbano
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | - Giusy Daniela Albano
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy; Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S.), Sezione di Pneumologia, University of Palermo, Palermo, Italy
| | - Giulia Anzalone
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | - Anna Bonanno
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | - Loredana Riccobono
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | - Caterina Di Sano
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | - Rosalia Gagliardo
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | - Liboria Siena
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | | | - Mark Gjomarkaj
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy
| | - Mirella Profita
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), Italian National Research Council (CNR), Palermo, Italy.
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Khan JH, Lababidi HMS, Al-Moamary MS, Zeitouni MO, AL-Jahdali HH, Al-Amoudi OS, Wali SO, Idrees MM, Al-Shimemri AA, Al Ghobain MO, Alorainy HS, Al-Hajjaj MS. The Saudi Guidelines for the Diagnosis and Management of COPD. Ann Thorac Med 2014; 9:55-76. [PMID: 24791168 PMCID: PMC4005164 DOI: 10.4103/1817-1737.128843] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 12/26/2022] Open
Abstract
The Saudi Thoracic Society (STS) launched the Saudi Initiative for Chronic Airway Diseases (SICAD) to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease (COPD). This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test (CAT) and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation (<2 in the past year) can be classified as either Class I when they have less symptoms (CAT < 10) or Class II when they have more symptoms (CAT ≥ 10). High-risk COPD patients, as manifested with ≥2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score ≥10. The article also discusses the diagnosis and management of acute exacerbations in COPD.
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Affiliation(s)
- Javed H. Khan
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Kingdom of Saudi Arabia
| | - Hani M. S. Lababidi
- Department of Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed S. Al-Moamary
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Hamdan H. AL-Jahdali
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Omar S. Al-Amoudi
- College of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Siraj O. Wali
- College of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah A. Al-Shimemri
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed O. Al Ghobain
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Hassan S. Alorainy
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
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Kew KM, Dias S, Cates CJ. Long-acting inhaled therapy (beta-agonists, anticholinergics and steroids) for COPD: a network meta-analysis. Cochrane Database Syst Rev 2014; 2014:CD010844. [PMID: 24671923 PMCID: PMC10879916 DOI: 10.1002/14651858.cd010844.pub2] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pharmacological therapy for chronic obstructive pulmonary disease (COPD) is aimed at relieving symptoms, improving quality of life and preventing or treating exacerbations.Treatment tends to begin with one inhaler, and additional therapies are introduced as necessary. For persistent or worsening symptoms, long-acting inhaled therapies taken once or twice daily are preferred over short-acting inhalers. Several Cochrane reviews have looked at the risks and benefits of specific long-acting inhaled therapies compared with placebo or other treatments. However for patients and clinicians, it is important to understand the merits of these treatments relative to each other, and whether a particular class of inhaled therapies is more beneficial than the others. OBJECTIVES To assess the efficacy of treatment options for patients whose chronic obstructive pulmonary disease cannot be controlled by short-acting therapies alone. The review will not look at combination therapies usually considered later in the course of the disease.As part of this network meta-analysis, we will address the following issues.1. How does long-term efficacy compare between different pharmacological treatments for COPD?2. Are there limitations in the current evidence base that may compromise the conclusions drawn by this network meta-analysis? If so, what are the implications for future research? SEARCH METHODS We identified randomised controlled trials (RCTs) in existing Cochrane reviews by searching the Cochrane Database of Systematic Reviews (CDSR). In addition, we ran a comprehensive citation search on the Cochrane Airways Group Register of trials (CAGR) and checked manufacturer websites and reference lists of other reviews. The most recent searches were conducted in September 2013. SELECTION CRITERIA We included parallel-group RCTs of at least 6 months' duration recruiting people with COPD. Studies were included if they compared any of the following treatments versus any other: long-acting beta2-agonists (LABAs; formoterol, indacaterol, salmeterol); long-acting muscarinic antagonists (LAMAs; aclidinium, glycopyrronium, tiotropium); inhaled corticosteroids (ICSs; budesonide, fluticasone, mometasone); combination long-acting beta2-agonist (LABA) and inhaled corticosteroid (LABA/ICS) (formoterol/budesonide, formoterol/mometasone, salmeterol/fluticasone); and placebo. DATA COLLECTION AND ANALYSIS We conducted a network meta-analysis using Markov chain Monte Carlo methods for two efficacy outcomes: St George's Respiratory Questionnaire (SGRQ) total score and trough forced expiratory volume in one second (FEV1). We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (placebo). We assumed that treatment effects were similar within treatment classes (LAMA, LABA, ICS, LABA/ICS). We present estimates of class effects, variability between treatments within each class and individual treatment effects compared with every other.To justify the analyses, we assessed the trials for clinical and methodological transitivity across comparisons. We tested the robustness of our analyses by performing sensitivity analyses for lack of blinding and by considering six- and 12-month data separately. MAIN RESULTS We identified 71 RCTs randomly assigning 73,062 people with COPD to 184 treatment arms of interest. Trials were similar with regards to methodology, inclusion and exclusion criteria and key baseline characteristics. Participants were more often male, aged in their mid sixties, with FEV1 predicted normal between 40% and 50% and with substantial smoking histories (40+ pack-years). The risk of bias was generally low, although missing information made it hard to judge risk of selection bias and selective outcome reporting. Fixed effects were used for SGRQ analyses, and random effects for Trough FEV1 analyses, based on model fit statistics and deviance information criteria (DIC). SGRQ SGRQ data were available in 42 studies (n = 54,613). At six months, 39 pairwise comparisons were made between 18 treatments in 25 studies (n = 27,024). Combination LABA/ICS was the highest ranked intervention, with a mean improvement over placebo of -3.89 units at six months (95% credible interval (CrI) -4.70 to -2.97) and -3.60 at 12 months (95% CrI -4.63 to -2.34). LAMAs and LABAs were ranked second and third at six months, with mean differences of -2.63 (95% CrI -3.53 to -1.97) and -2.29 (95% CrI -3.18 to -1.53), respectively. Inhaled corticosteroids were ranked fourth (MD -2.00, 95% CrI -3.06 to -0.87). Class differences between LABA, LAMA and ICS were less prominent at 12 months. Indacaterol and aclidinium were ranked somewhat higher than other members of their classes, and formoterol 12 mcg, budesonide 400 mcg and formoterol/mometasone combination were ranked lower within their classes. There was considerable overlap in credible intervals and rankings for both classes and individual treatments. Trough FEV1 Trough FEV1 data were available in 46 studies (n = 47,409). At six months, 41 pairwise comparisons were made between 20 treatments in 31 studies (n = 29,271). As for SGRQ, combination LABA/ICS was the highest ranked class, with a mean improvement over placebo of 133.3 mL at six months (95% CrI 100.6 to 164.0) and slightly less at 12 months (mean difference (MD) 100, 95% CrI 55.5 to 140.1). LAMAs (MD 103.5, 95% CrI 81.8 to 124.9) and LABAs (MD 99.4, 95% CrI 72.0 to 127.8) showed roughly equivalent results at six months, and ICSs were the fourth ranked class (MD 65.4, 95% CrI 33.1 to 96.9). As with SGRQ, initial differences between classes were not so prominent at 12 months. Indacaterol and salmeterol/fluticasone were ranked slightly better than others in their class, and formoterol 12, aclidinium, budesonide and formoterol/budesonide combination were ranked lower within their classes. All credible intervals for individual rankings were wide. AUTHORS' CONCLUSIONS This network meta-analysis compares four different classes of long-acting inhalers for people with COPD who need more than short-acting bronchodilators. Quality of life and lung function were improved most on combination inhalers (LABA and ICS) and least on ICS alone at 6 and at 12 months. Overall LAMA and LABA inhalers had similar effects, particularly at 12 months. The network has demonstrated the benefit of ICS when added to LABA for these outcomes in participants who largely had an FEV1 that was less than 50% predicted, but the additional expense of combination inhalers and any potential for increased adverse events (which has been established by other reviews) require consideration. Our findings are in keeping with current National Institute for Health and Care Excellence (NICE) guidelines.
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Affiliation(s)
- Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
| | - Sofia Dias
- University of BristolSchool of Social and Community MedicineCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | - Christopher J Cates
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
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Abstract
BACKGROUND Inhaled corticosteroids (ICS) are anti-inflammatory drugs that have proven benefits for people with worsening symptoms of chronic obstructive pulmonary disease (COPD) and repeated exacerbations. They are commonly used as combination inhalers with long-acting beta2-agonists (LABA) to reduce exacerbation rates and all-cause mortality, and to improve lung function and quality of life. The most common combinations of ICS and LABA used in combination inhalers are fluticasone and salmeterol, budesonide and formoterol and a new formulation of fluticasone in combination with vilanterol, which is now available. ICS have been associated with increased risk of pneumonia, but the magnitude of risk and how this compares with different ICS remain unclear. Recent reviews conducted to address their safety have not compared the relative safety of these two drugs when used alone or in combination with LABA. OBJECTIVES To assess the risk of pneumonia associated with the use of fluticasone and budesonide for COPD. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), clinicaltrials.gov, reference lists of existing systematic reviews and manufacturer websites. The most recent searches were conducted in September 2013. SELECTION CRITERIA We included parallel-group randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies were included if they compared the ICS budesonide or fluticasone versus placebo, or either ICS in combination with a LABA versus the same LABA as monotherapy for people with COPD. DATA COLLECTION AND ANALYSIS Two review authors independently extracted study characteristics, numerical data and risk of bias information for each included study.We looked at direct comparisons of ICS versus placebo separately from comparisons of ICS/LABA versus LABA for all outcomes, and we combined these with subgroups when no important heterogeneity was noted. After assessing for transitivity, we conducted an indirect comparison to compare budesonide versus fluticasone monotherapy, but we could not do the same for the combination therapies because of systematic differences between the budesonide and fluticasone combination data sets.When appropriate, we explored the effects of ICS dose, duration of ICS therapy and baseline severity on the primary outcome. Findings of all outcomes are presented in 'Summary of findings' tables using GRADEPro. MAIN RESULTS We found 43 studies that met the inclusion criteria, and more evidence was provided for fluticasone (26 studies; n = 21,247) than for budesonide (17 studies; n = 10,150). Evidence from the budesonide studies was more inconsistent and less precise, and the studies were shorter. The populations within studies were more often male with a mean age of around 63, mean pack-years smoked over 40 and mean predicted forced expiratory volume of one second (FEV1) less than 50%.High or uneven dropout was considered a high risk of bias in almost 40% of the trials, but conclusions for the primary outcome did not change when the trials at high risk of bias were removed in a sensitivity analysis.Fluticasone increased non-fatal serious adverse pneumonia events (requiring hospital admission) (odds ratio (OR) 1.78, 95% confidence interval (CI) 1.50 to 2.12; 18 more per 1000 treated over 18 months; high quality), and no evidence suggested that this outcome was reduced by delivering it in combination with salmeterol or vilanterol (subgroup differences: I(2) = 0%, P value 0.51), or that different doses, trial duration or baseline severity significantly affected the estimate. Budesonide also increased non-fatal serious adverse pneumonia events compared with placebo, but the effect was less precise and was based on shorter trials (OR 1.62, 95% CI 1.00 to 2.62; six more per 1000 treated over nine months; moderate quality). Some of the variation in the budesonide data could be explained by a significant difference between the two commonly used doses: 640 mcg was associated with a larger effect than 320 mcg relative to placebo (subgroup differences: I(2) = 74%, P value 0.05).An indirect comparison of budesonide versus fluticasone monotherapy revealed no significant differences with respect to serious adverse events (pneumonia-related or all-cause) or mortality. The risk of any pneumonia event (i.e. less serious cases treated in the community) was higher with fluticasone than with budesonide (OR 1.86, 95% CI 1.04 to 3.34); this was the only significant difference reported between the two drugs. However, this finding should be interpreted with caution because of possible differences in the assignment of pneumonia diagnosis, and because no trials directly compared the two drugs.No significant difference in overall mortality rates was observed between either of the inhaled steroids and the control interventions (both high-quality evidence), and pneumonia-related deaths were too rare to permit conclusions to be drawn. AUTHORS' CONCLUSIONS Budesonide and fluticasone, delivered alone or in combination with a LABA, are associated with increased risk of serious adverse pneumonia events, but neither significantly affected mortality compared with controls. The safety concerns highlighted in this review should be balanced with recent cohort data and established randomised evidence of efficacy regarding exacerbations and quality of life. Comparison of the two drugs revealed no statistically significant difference in serious pneumonias, mortality or serious adverse events. Fluticasone was associated with higher risk of any pneumonia when compared with budesonide (i.e. less serious cases dealt with in the community), but variation in the definitions used by the respective manufacturers is a potential confounding factor in their comparison.Primary research should accurately measure pneumonia outcomes and should clarify both the definition and the method of diagnosis used, especially for new formulations such as fluticasone furoate, for which little evidence of the associated pneumonia risk is currently available. Similarly, systematic reviews and cohorts should address the reliability of assigning 'pneumonia' as an adverse event or cause of death and should determine how this affects the applicability of findings.
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Affiliation(s)
- Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
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Kruis AL, Ställberg B, Jones RCM, Tsiligianni IG, Lisspers K, van der Molen T, Kocks JWH, Chavannes NH. Primary care COPD patients compared with large pharmaceutically-sponsored COPD studies: an UNLOCK validation study. PLoS One 2014; 9:e90145. [PMID: 24598945 PMCID: PMC3943905 DOI: 10.1371/journal.pone.0090145] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 01/27/2014] [Indexed: 11/19/2022] Open
Abstract
Background Guideline recommendations for chronic obstructive pulmonary disease (COPD) are based on the results of large pharmaceutically-sponsored COPD studies (LPCS). There is a paucity of data on disease characteristics at the primary care level, while the majority of COPD patients are treated in primary care. Objective We aimed to evaluate the external validity of six LPCS (ISOLDE, TRISTAN, TORCH, UPLIFT, ECLIPSE, POET-COPD) on which current guidelines are based, in relation to primary care COPD patients, in order to inform future clinical practice guidelines and trials. Methods Baseline data of seven primary care databases (n = 3508) from Europe were compared to baseline data of the LPCS. In addition, we examined the proportion of primary care patients eligible to participate in the LPCS, based on inclusion criteria. Results Overall, patients included in the LPCS were younger (mean difference (MD)-2.4; p = 0.03), predominantly male (MD 12.4; p = 0.1) with worse lung function (FEV1% MD -16.4; p<0.01) and worse quality of life scores (SGRQ MD 15.8; p = 0.01). There were large differences in GOLD stage distribution compared to primary care patients. Mean exacerbation rates were higher in LPCS, with an overrepresentation of patients with ≥1 and ≥2 exacerbations, although results were not statistically significant. Our findings add to the literature, as we revealed hitherto unknown GOLD I exacerbation characteristics, showing 34% of mild patients had ≥1 exacerbations per year and 12% had ≥2 exacerbations per year. The proportion of primary care patients eligible for inclusion in LPCS ranged from 17% (TRISTAN) to 42% (ECLIPSE, UPLIFT). Conclusion Primary care COPD patients stand out from patients enrolled in LPCS in terms of gender, lung function, quality of life and exacerbations. More research is needed to determine the effect of pharmacological treatment in mild to moderate patients. We encourage future guideline makers to involve primary care populations in their recommendations.
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Affiliation(s)
- Annemarije L. Kruis
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
- * E-mail:
| | - Björn Ställberg
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Rupert C. M. Jones
- Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
| | - Ioanna G. Tsiligianni
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands
- Agia Barbara Health Care Centre, Heraklion, Crete, Greece
| | - Karin Lisspers
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Thys van der Molen
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands
| | - Jan Willem H. Kocks
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands
| | - Niels H. Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
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Emerman CL. Effectiveness of Inhaled Steroids in the Management of Chronic Obstructive Pulmonary Disease. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Thomas M, Radwan A, Stonham C, Marshall S. COPD exacerbation frequency, pharmacotherapy and resource use: an observational study in UK primary care. COPD 2013; 11:300-9. [PMID: 24152210 DOI: 10.3109/15412555.2013.841671] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) management represents a significant health resource use burden. Understanding of current resource use, treatment strategies and outcomes can improve future COPD management, for patient benefit and to aid efficient service delivery. This study aimed to describe exacerbation frequency, pharmacotherapy and health resource use in COPD management in routine UK primary care. A retrospective, observational study using routine clinical records of 511 patients with COPD, was undertaken in 10 General Practices in England. Up to 3 years' patient data were collected and analysed. 75% (234/314) patients with mild-moderate COPD (≥50% predicted FEV1) received inhaled corticosteroids (ICS). 11% of patients (54/511) received ICS monotherapy. Mean (standard deviation) annual exacerbation frequency was 1.1 (1.2) in mild-moderate, 1.7 (1.6) in severe (30-49% predicted FEV1) and 2.2 (2.0) in very severe (<30% predicted FEV1) COPD. 14% patients (69/511) had a mean exacerbation frequency of ≥3/year ('frequent-exacerbators'); 9% (27/314) of patients with mild-moderate, 19% (27/145) with severe and 29% (15/52) with very severe COPD. 14% (10/69) of frequent-exacerbators failed to receive inhaled long-acting beta agonists (LABA), 25% (17/69) inhaled long-acting muscarinic antagonists (LAMA), and 12% (`/69) ICS. Frequent-exacerbators had a median of 6.67 primary care contacts/year, 1.0 secondary care visits/year and 21% were hospitalised for COPD/year. Inhaled therapy was frequently inappropriate, with over-use of ICS in patients with mild-moderate COPD. COPD exacerbations were associated with high health resource use and occurred at all levels of disease severity. COPD management strategies should encompass risk-stratification for both exacerbation frequency and physiological impairment.
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Affiliation(s)
- Mike Thomas
- 1Department of Primary Care Research, University of Southampton , UK
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Price D, Yawn B, Brusselle G, Rossi A. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:92-100. [PMID: 23135217 DOI: 10.4104/pcrj.2012.00092] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While the pharmacological management of chronic obstructive pulmonary disease (COPD) has evolved from the drugs used to treat asthma, the treatment models are different and the two diseases require clear differential diagnosis in order to determine the correct therapeutic strategy. In contrast to the almost universal requirement for anti-inflammatory treatment of persistent asthma, the efficacy of inhaled corticosteroids (ICS) is less well established in COPD and their role in treatment is limited. There is some evidence of a preventive effect of ICS on exacerbations in patients with COPD, but there is little evidence for an effect on mortality or lung function decline. As a result, treatment guidelines recommend the use of ICS in patients with severe or very severe disease (forced expiratory volume in 1 second <50% predicted) and repeated exacerbations. Patients with frequent exacerbations - a phenotype that is stable over time - are likely to be less common among those with moderate COPD (many of whom are managed in primary care) than in those with more severe disease. The indiscriminate use of ICS in COPD may expose patients to an unnecessary increase in the risk of side-effects such as pneumonia, osteoporosis, diabetes and cataracts, while wasting healthcare spending and potentially diverting attention from other more appropriate forms of management such as pulmonary rehabilitation and maximal bronchodilator use. Physicians should carefully weigh the likely benefits of ICS use against the potential risk of side-effects and costs in individual patients with COPD.
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Affiliation(s)
- David Price
- Primary Care Respiratory Society UK Professor of Primary Care Respiratory Medicine, University of Aberdeen, UK.
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Trigueros Carrero JA. How should we define and classify exacerbations in chronic obstructive pulmonary disease? Expert Rev Respir Med 2013; 7:33-41. [PMID: 23551022 DOI: 10.1586/ers.13.16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic disorder whose clinical course may be punctuated by exacerbations characterized by a sudden symptom worsening beyond the expected daily variations. Exacerbations bear clinical and prognostic relevance, and may result in marked functional and clinical deterioration. The varying presentations of COPD mean that exacerbations, although more frequent in patients with severe or very severe disease, may occur regardless of the degree of functional impairment. The new Spanish COPD Guideline (GesEPOC) has provided new insights into the management of the disease. The GesEPOC defines various disease phenotypes with different clinical, prognostic and therapeutic implications. One of these phenotypes is the so-called 'exacerbator', characterized by the incidence of an increased number of exacerbations (two or more moderate-severe exacerbations in the last year). An exacerbation must be defined by: an increase in symptom intensity occurring after a certain period of time since the last exacerbation (so that treatment failure can be excluded as the cause of the event); and the contribution of social criteria or reasons concerning the choice of therapy. The availability of certain tools to detect exacerbations would enable establishment of a homogeneous definition of exacerbation, and improved diagnosis, a suitable treatment choice and a more appropriate patient selection for clinical studies. Validated clinical questionnaires and biomarkers are the most helpful instruments to reach the above objectives. Following the clinical diagnosis of a COPD exacerbation, associated comorbidities must be evaluated and an etiologic diagnosis must be made, all of which will partially drive the choice of treatment. Once a diagnosis has been made, the severity of the exacerbation should be established in order to define where and how the patient should be treated. Based on the patient's clinical history, clinical examination and diagnostic tests, the severity will be classified in one of these four degrees: very severe, severe, moderate and mild.
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Restrepo RD, Tate A, Coquat J. Evaluation of salmeterol xinafoate plus fluticasone propionate for the treatment of chronic obstructive pulmonary disease. Expert Opin Pharmacother 2013; 14:1993-2002. [PMID: 23898819 DOI: 10.1517/14656566.2013.823949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Current clinical guidelines recommend long-acting bronchodilators as the mainstay of the pharmacotherapy of patients with chronic obstructive pulmonary disease (COPD). Inhaled corticosteroids (ICS), in conjunction with long-acting beta-agonists (LABA), are routinely considered at severe and very severe stages of COPD when patients lack adequate response to single-therapy with LABAs. Although the study methodologies evaluating the clinical effectiveness of the combination therapy using salmeterol and fluticasone (SAL/FLU) for patients with COPD have been questioned, a number of studies have suggested that using ICS, in combination with a LABA agent, may improve survival of patients with COPD. AREAS COVERED This article attempts to review the most current evidence for using SAL/FLU in the management of COPD and summarizes the results of outcome measures reported in randomized controlled trials. EXPERT OPINION Until new forms of drug combinations are made available, the use of dual-therapy containing a LABA and ICS remain as the most logical and appropriate approach for the treatment of patients suffering from severe and very severe COPD with repeated exacerbations.
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Affiliation(s)
- Ruben D Restrepo
- The University of Texas Health Science Center, Department of Respiratory Care , MSC 6248, San Antonio TX 78229 , USA
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Yawn BP, Li Y, Tian H, Zhang J, Arcona S, Kahler KH. Inhaled corticosteroid use in patients with chronic obstructive pulmonary disease and the risk of pneumonia: a retrospective claims data analysis. Int J Chron Obstruct Pulmon Dis 2013; 8:295-304. [PMID: 23836970 PMCID: PMC3699136 DOI: 10.2147/copd.s42366] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [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
BACKGROUND The use of inhaled corticosteroids in patients with chronic obstructive pulmonary disease (COPD) has been associated with an increased risk of pneumonia in controlled clinical trials and case-control analyses. OBJECTIVE Using claims databases as a research model of real-world diagnosis and treatment, to determine if the use and dose of inhaled corticosteroids (ICS) among patients with newly diagnosed COPD are associated with increased risk of pneumonia. PATIENTS AND METHODS This was a retrospective cohort analysis of patients diagnosed with COPD between January 01, 2006 and September 30, 2010, drawn from databases (years 2006-2010). Patients (aged ≥45 years) were followed until first pneumonia diagnosis, end of benefit enrollment, or December 31, 2010, whichever was earliest. A Cox proportional hazard model was used to assess the association of ICS use and risk of pneumonia, controlling for baseline characteristics. Daily ICS use was classified into low, medium, and high doses (1 μg-499 μg, 500 μg-999 μg, and ≥1000 μg fluticasone equivalents daily) and was modeled as a time-dependent variable. RESULTS Among 135,445 qualifying patients with a total of 243,097 person-years, there were 1020 pneumonia incidences out of 5677 person-years on ICS (crude incidence rate, 0.180 per person-year), and 27,730 pneumonia incidences out of 237,420 person-years not on ICS (crude incidence rate, 0.117 per person-year). ICS use was associated with a dose-related increase in risk of pneumonia, with adjusted hazard ratios (versus no use; (95% confidence interval) of 1.38 (1.27-1.49) for low-dose users, 1.69 (1.52-1.88) for medium-dose users, and 2.57 (1.98-3.33) for high-dose users (P < 0.01 versus no use and between doses). CONCLUSION The use of ICS in newly diagnosed patients with COPD is potentially associated with a dose-related increase in the risk of pneumonia.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, MN 55904, USA.
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Larsson K, Janson C, Lisspers K, Jørgensen L, Stratelis G, Telg G, Ställberg B, Johansson G. Combination of budesonide/formoterol more effective than fluticasone/salmeterol in preventing exacerbations in chronic obstructive pulmonary disease: the PATHOS study. J Intern Med 2013; 273:584-94. [PMID: 23495860 DOI: 10.1111/joim.12067] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Combinations of inhaled corticosteroids (ICSs) and long-acting β2 -agonists (LABAs) are recommended for patients with moderate and severe chronic obstructive pulmonary disease (COPD). However, it is not known whether different fixed combinations are equally effective. The aim of this study was to investigate exacerbation rates in primary care patients with COPD treated with budesonide/formoterol compared with fluticasone/salmeterol. METHODS Patients with physician-diagnosed COPD and a record of postdiagnosis treatment with a fixed combination of budesonide/formoterol or fluticasone/salmeterol were included. Data from primary care medical records were linked to those from Swedish national hospital, drug and cause of death registers. Pairwise (1 : 1) propensity score matching was carried out at the index date (first prescription) by prescribed fixed ICS/LABA combination. Exacerbations were defined as hospitalizations, emergency visits and collection of oral steroids or antibiotics for COPD. Yearly event rates were compared using Poisson regression. RESULTS Matching of 9893 patients (7155 budesonide/formoterol and 2738 fluticasone/salmeterol) yielded two cohorts of 2734 patients, comprising 19 170 patient-years. The exacerbation rates were 0.80 and 1.09 per patient-year in the budesonide/formoterol and fluticasone/salmeterol groups, respectively (difference of 26.6%; P < 0.0001); yearly rates for COPD-related hospitalizations were 0.15 and 0.21, respectively (difference of 29.1%; P < 0.0001). All other healthcare outcomes were also significantly reduced with budesonide/formoterol versus fluticasone/salmeterol. CONCLUSIONS Long-term treatment with fixed combination budesonide/formoterol was associated with fewer healthcare utilization-defined exacerbations than fluticasone/salmeterol in patients with moderate and severe COPD.
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Affiliation(s)
- K Larsson
- Unit of Lung and Allergy Research, National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Miravitlles M, Sicras A, Crespo C, Cuesta M, Brosa M, Galera J, Lahoz R, Lleonart M, Riera MI. Costs of chronic obstructive pulmonary disease in relation to compliance with guidelines: a study in the primary care setting. Ther Adv Respir Dis 2013; 7:139-50. [PMID: 23653458 DOI: 10.1177/1753465813484080] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this study was to analyse the economic impact of nonadherence to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines in patients with chronic obstructive pulmonary disease (COPD). METHODS A retrospective analysis was carried out on a claim database. Patients aged at least 40 years with a diagnosis of COPD were eligible for this analysis. Demographics, medical data and use of resources were collected and direct and indirect costs were analysed (from January 2008 to June 2009). A probabilistic multivariate sensitivity analysis of avoided costs was carried out. All results are presented in annualized form and costs are expressed in Euros (2009). RESULTS A total of 1365 patients were included, 79.5% were men. The mean age (±standard deviation) was 71.4 (±10.3) years, the mean forced expiratory volume in 1 s (FEV1) was 65.3% and they had a COPD history of 5.5 (±2.9) years. Patients were divided into an adherent group and a nonadherent group depending on whether therapeutic recommendations according to severity defined in the GOLD guidelines (2007) were followed. Patients in both groups were also classified as having stage II (FEV1 < 80% and < 50%) or stage III disease (FEV1 < 50% and ≥ 30%). The total annual drug cost per patient in the nonadherent group was €771.5 while it was only €426.4 for the adherent group. The average direct cost per patient per year in the nonadherent stage II group was €1465 (±971) and it rose to €2942 (±1918) for patients in the nonadherent group with stage III disease. The potential saving from the implementation of the GOLD guidelines in stage II COPD amounted to €758 per patient per year (68% saving on drug cost). In contrast, the cost for patients with stage III disease was higher in the adherent group versus the nonadherent group (€2468). CONCLUSIONS The cost of COPD may vary according to compliance with the GOLD guidelines. The cost observed for patients with stage II disease is higher than expected in patients who adhere to treatment, but patients with stage III disease treated according to the GOLD guidelines had significantly higher treatment costs.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Pg. vall d'Hebron 119-129, 08035 Barcelona, Spain.
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Marchetti N, Criner GJ, Albert RK. Preventing Acute Exacerbations and Hospital Admissions in COPD. Chest 2013; 143:1444-1454. [DOI: 10.1378/chest.12-1801] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Greulich T, Koczulla AR, Vogelmeier C. [Chronic obstructive pulmonary disease : new pharmacotherapeutic options]. Internist (Berl) 2013; 53:1364-70, 1373-5. [PMID: 22955248 DOI: 10.1007/s00108-012-3119-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Data about the clinical presentation of chronic obstructive pulmonary disease (COPD) have resulted in a new classification of the disease. The degree of airflow limitation has been amended by symptoms and exacerbation rate. The standard pharmacotherapy of stable COPD is in transition, as fixed combinations of long acting beta agonists and long acting anticholinergics are in the late stages of clinical development. On this background inhaled corticosteroids will need to be re-evaluated. Roflumilast is a recently approved therapeutic option that primarily diminishes exacerbation frequency in patients with chronic bronchitis and severe airflow obstruction (FEV(1) < 50%). In COPD patients with acute exacerbations procalcitonin levels can be used to guide antibiotic therapy. Comparable clinical outcomes can be achieved while using significantly less amounts of antibiotics.
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Affiliation(s)
- T Greulich
- Klinik für Innere Medizin, Schwerpunkt Pneumologie, Universitätsklinikum Giessen und Marburg, Philipps-Universität Marburg, Deutschland.
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Influence of salmeterol/fluticasone via single versus separate inhalers on exacerbations in severe/very severe COPD. Respir Med 2013; 107:542-9. [PMID: 23337300 DOI: 10.1016/j.rmed.2012.12.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 12/17/2012] [Accepted: 12/24/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with severe or very severe chronic obstructive pulmonary disease (COPD) frequently suffer repeated exacerbations generating high health care utilization costs. Combined corticosteroid and bronchodilator treatment using a single inhaler might - via improved compliance - reduce exacerbation rates. OBJECTIVES Our aim was to obtain descriptive data on exacerbation rates in patients with severe or very severe COPD (GOLD Stages III and IV as per GOLD 2009 classification) receiving salmeterol xinafoate/fluticasone propionate via a single inhaler (SFC) or via separate inhalers (Sal/FP) in addition to individual existing therapy in order to investigate the potential benefit of a fixed combination device as compared with two separate devices due to potentially improved patients' compliance. METHODS This prospective, randomized, open-label, parallel-group, multi-center, exploratory study was conducted in Germany in 2007-2009. Patients were required to have suffered ≥ 2 moderate/severe exacerbations in the preceding year. RESULTS 213 patients (SFC: 108 patients, Sal/FP: 105 patients) from 23 centers were evaluated. Approximately 25% of patients showed COPD Stage IV. On average patients had suffered 2.3 ± 0.6 moderate/severe exacerbations in the preceding year. The annual rate of moderate/severe exacerbations observed in the study was similar in both treatment groups (SFC: 0.86 ± 0.13; Sal/FP: 0.86 ± 0.14; exacerbation rate ratio SFC/Sal/FP: 1.00; p = 0.73; negative binomial model). Compliance was high and comparable in both groups. Besides COPD exacerbations, pneumonia (5.6%) and nasopharyngitis (5.2%) were the most common adverse events. CONCLUSION Observed exacerbation rates were lower than those reported at baseline. No substantial difference was observed between administration of salmeterol xinafoate/fluticasone propionate via a single inhaler and separate inhalers. Treatment was safe and well tolerated. ClinicalTrials.gov Identifier: NCT00527826.
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Yang IA, Clarke MS, Sim EHA, Fong KM. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012; 2012:CD002991. [PMID: 22786484 PMCID: PMC8992433 DOI: 10.1002/14651858.cd002991.pub3] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD. OBJECTIVES To determine the efficacy and safety of inhaled corticosteroids in stable patients with COPD, in terms of objective and subjective outcomes. SEARCH METHODS A pre-defined search strategy was used to search the Cochrane Airways Group Specialised Register for relevant literature. Searches are current as of July 2011. SELECTION CRITERIA We included randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short-term beta(2)-agonists and bronchial hyper-responsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. We also analysed data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials. MAIN RESULTS Fifty-five primary studies with 16,154 participants met the inclusion criteria. Long-term use of ICS (more than six months) did not consistently reduce the rate of decline in forced expiratory volume in one second (FEV(1)) in COPD patients (generic inverse variance analysis: mean difference (MD) 5.80 mL/year with ICS over placebo, 95% confidence interval (CI) -0.28 to 11.88, 2333 participants; pooled means analysis: 6.88 mL/year, 95% CI 1.80 to 11.96, 4823 participants), although one major trial demonstrated a statistically significant difference. There was no statistically significant effect on mortality in COPD patients (odds ratio (OR) 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long-term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: MD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants; pooled means analysis: MD -0.19 exacerbations per patient per year, 95% CI -0.30 to -0.08, 2253 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.65, 95% CI 2.03 to 3.46, 5586 participants) and hoarseness. In the long-term studies, the rate of pneumonia was increased in the ICS group compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.56, 95% CI 1.30 to 1.86, 6235 participants). The long-term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over three years. AUTHORS' CONCLUSIONS Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life and possibly reduced rate of decline in FEV(1)) against the potential side effects (oropharyngeal candidiasis and hoarseness, and risk of pneumonia).
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Affiliation(s)
- Ian A Yang
- Department of ThoracicMedicine, The Prince CharlesHospital, Brisbane, Australia.
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van den Berge M, Hop WCJ, van der Molen T, van Noord JA, Creemers JPHM, Schreurs AJM, Wouters EFM, Postma DS. Prediction and course of symptoms and lung function around an exacerbation in chronic obstructive pulmonary disease. Respir Res 2012; 13:44. [PMID: 22672621 PMCID: PMC3494574 DOI: 10.1186/1465-9921-13-44] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 04/04/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Frequent exacerbations induce a high burden to Chronic Obstructive Pulmonary Disease (COPD). We investigated the course of exacerbations in the published COSMIC study that investigated the effects of 1-year withdrawal of fluticasone after a 3-month run-in treatment period with salmeterol/fluticasone in patients with COPD. METHODS In 373 patients, we evaluated diary cards for symptoms, Peak Expiratory Flow (PEF), and salbutamol use and assessed their course during exacerbations. RESULTS There were 492 exacerbations in 224 patients. The level of symptoms of cough, sputum, dyspnea and nocturnal awakening steadily increased from 2 weeks prior to exacerbation, with a sharp rise during the last week. Symptoms of cough, sputum, and dyspnea reverted to baseline values at different rates (after 4, 4, and 7 weeks respectively), whereas symptoms of nocturnal awakening were still increased after eight weeks. The course of symptoms was similar around a first and second exacerbation. Increases in symptoms and salbutamol use and decreases in PEF were associated with a higher risk to develop an exacerbation, but with moderate predictive values, the areas under the receiver operating curves ranging from 0.63 to 0.70. CONCLUSIONS Exacerbations of COPD are associated with increased symptoms that persist for weeks and the course is very similar between a first and second exacerbation. COPD exacerbations are preceded by increased symptoms and salbutamol use and lower PEF, yet predictive values are too low to warrant daily use in clinical practice.
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Affiliation(s)
- Maarten van den Berge
- Department of Respiratory Medicine, University Medical Center Groningen, GRIAC Research Institute, University of Groningen, Groningen, The Netherlands.
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Effect of budesonide/formoterol pMDI on COPD exacerbations: A double-blind, randomized study. Respir Med 2012; 106:257-68. [DOI: 10.1016/j.rmed.2011.07.020] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 07/22/2011] [Accepted: 07/25/2011] [Indexed: 11/19/2022]
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