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BICKTON FANUELMECKSON, Mankhokwe T, Mitengo M, Limbani F, Shannon H, Rylance J, Chisati E. “My life is not going to be the same, my health is going to improve”: a cross-sectional qualitative study of patients’ experiences of living with chronic respiratory symptoms and their views on a proposed pulmonary rehabilitation program at Queen Elizabeth Central Hospital, Blantyre, Malawi. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17702.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Malawi’s population has a substantial burden of chronic respiratory symptoms. Elsewhere, patients with these symptoms have benefited from pulmonary rehabilitation (PR), a program of exercise training, education, and behaviour management. Practically, PR in Malawi may not be delivered in the same format as elsewhere due to substantial contextual differences. These differences necessitate adaptation of the intervention to Malawi’s setting to be acceptable and effective. This study explored patients’ experiences of living with chronic respiratory symptoms and their views on a proposed PR program at Queen Elizabeth Central Hospital, Blantyre, Malawi, to inform the design of an individualized and culturally adapted PR program. Methods: This was a cross-sectional qualitative study. Face-to-face, one-to-one semi-structured in-depth interviews were undertaken to data saturation. Interviews were audio-recorded, transcribed verbatim, and Chichewa transcripts were translated into English. The transcripts were anonymized and thematically analysed using an inductive approach. Results: We recruited 10 patients (five males and five females) with functionally limiting chronic respiratory symptoms, with documented causes including chronic obstructive pulmonary disease, asthma, post-tuberculosis lung disease, and bronchiectasis. Symptoms most frequently included dyspnoea, with associated functional limitations including the reduced performance of activities of daily living. Participants’ coping strategies most frequently included the use of inhalers. Participants were motivated to undertake the PR program owing to its anticipated benefits including improved health. They perceived transport costs and competing commitments as barriers to participation. The participant group gender mix and public nature of the program were considered socio-culturally sensitive by some participants. Conclusions: The functionally limiting dyspnoea most frequently experienced by the study participants would be amenable to a PR program. To ensure participation by eligible patients, pre-program assessments should consider patient access to transport, suitability of the timing for the program’s sessions, and patient views on organizational aspects of the program considered social-culturally sensitive.
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Miravitlles M, Calle M, Molina J, Almagro P, Gómez JT, Trigueros JA, Cosío BG, Casanova C, López-Campos JL, Riesco JA, Simonet P, Rigau D, Soriano JB, Ancochea J, Soler-Cataluña JJ. [Translated article] Spanish COPD guidelines (GesEPOC) 2021: Updated pharmacological treatment of stable COPD. Arch Bronconeumol 2022. [DOI: 10.1016/j.arbres.2021.03.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Miravitlles M, Calle M, Molina J, Almagro P, Gómez JT, Trigueros JA, Cosío BG, Casanova C, López-Campos JL, Riesco JA, Simonet P, Rigau D, Soriano JB, Ancochea J, Soler-Cataluña JJ. Spanish COPD Guidelines (GesEPOC) 2021: Updated Pharmacological treatment of stable COPD. Arch Bronconeumol 2022; 58:69-81. [PMID: 33840553 DOI: 10.1016/j.arbres.2021.03.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 01/16/2023]
Abstract
The Spanish COPD Guidelines (GesEPOC) were first published in 2012, and since then have undergone a series of updates incorporating new evidence on the diagnosis and treatment of COPD. GesEPOC was drawn up in partnership with scientific societies involved in the treatment of COPD and the Spanish Patients' Forum. Their recommendations are based on an evaluation of the evidence using GRADE methodology, and a narrative description of the evidence in areas in which GRADE cannot be applied. In this article, we summarize the recommendations on the pharmacological treatment of stable COPD based on 9 PICO questions. COPD treatment is a 4-step process: 1) diagnosis, 2) determination of the risk level, 3) initial and subsequent inhaled therapy, and 4) identification and management of treatable traits. For the selection of inhaled therapy, high-risk patients are divided into 3 phenotypes: non-exacerbator, eosinophilic exacerbator, and non-eosinophilic exacerbator. Some treatable traits are general and should be investigated in all patients, such as smoking or inhalation technique, while others affect severe patients in particular, such as chronic hypoxemia and chronic bronchial infection. COPD treatment is based on long-acting bronchodilators with single agents or in combination, depending on the patient's risk level. Eosinophilic exacerbators must receive inhaled corticosteroids, while non-eosinophilic exacerbators require a more detailed evaluation to choose the best therapeutic option. The new GesEPOC also includes recommendations on the withdrawal of inhaled corticosteroids and on indications for alpha-1 antitrypsin treatment. GesEPOC offers a more individualized approach to COPD treatment tailored according to the clinical characteristics of patients and their level of complexity.
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Affiliation(s)
- Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos. Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | | | - Pere Almagro
- Servicio de Medicina Interna, Hospital Universitario Mutua de Terrassa, Terrassa, España
| | | | | | - Borja G Cosío
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, España
| | - Ciro Casanova
- Servicio de Neumología-Unidad de Investigación, Hospital Universitario Nuestra Señora de La Candelaria. Universidad de La Laguna, Tenerife, España
| | - José Luis López-Campos
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, España
| | - Juan Antonio Riesco
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, España
| | - Pere Simonet
- Centro de Salud Viladecans-2, Atención Primaria Costa de Ponent-Institut Català de la Salut. Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Departament de Ciències Clíniques, Universitat Barcelona, Barcelona, España
| | - David Rigau
- Centro Cochrane Iberoamericano, Barcelona, España
| | - Joan B Soriano
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario de La Princesa. Universidad Autónoma de Madrid, Madrid, España
| | - Julio Ancochea
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario de La Princesa. Universidad Autónoma de Madrid, Madrid, España
| | - Juan José Soler-Cataluña
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Arnau de Vilanova-Lliria, Valencia, España
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Spanish COPD guidelines (GesEPOC) 2021: Updated pharmacological treatment of stable COPD. ACTA ACUST UNITED AC 2021. [DOI: 10.1016/j.arbr.2021.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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5
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Bakeer M, Funk GC, Valipour A. Chronic obstructive pulmonary disease phenotypes: imprint on pharmacological and non-pharmacological therapy. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1472. [PMID: 33313217 PMCID: PMC7723612 DOI: 10.21037/atm-20-2219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease associated with significant morbidity and mortality. Over the past few years, there has been cumulating interest in describing this heterogeneity and using this information to group patients into different COPD phenotypes. The term phenotype is defined as single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes. It describes also the physical appearance or biochemical characteristics which result from the genotype-environment interaction. Furthermore, it clearly identifies subgroups with a significant impact in the prognosis. Recently, approaches to COPD phenotyping have been significantly enhanced in tandem with developments in understanding the disease’s various pathological, clinical and genetic features. This knowledge inspired the researchers to investigate more tailored therapeutic strategies that could not only give a more potent effect but also help to avoid the traditional therapy’s undesirable side effects. Eventually, it could be said that the phenotypic approach to COPD in the last decade had a huge impact on daily practice and management delivered to COPD patients. In this review, we highlight the impact of pharmacological and non-pharmacological treatment options on COPD outcomes, using a personalized treatment strategy based on different phenotypes.
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Affiliation(s)
- Mostafa Bakeer
- Chest Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria
| | - Georg-Christian Funk
- Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria
| | - Arschang Valipour
- Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria
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Grossi CM, Richardson K, Savva GM, Fox C, Arthur A, Loke YK, Steel N, Brayne C, Matthews FE, Robinson L, Myint PK, Maidment ID. Increasing prevalence of anticholinergic medication use in older people in England over 20 years: cognitive function and ageing study I and II. BMC Geriatr 2020; 20:267. [PMID: 32736640 PMCID: PMC7393714 DOI: 10.1186/s12877-020-01657-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/16/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Anticholinergic medication use is linked with increased cognitive decline, dementia, falls and mortality, and their use should be limited in older people. Here we estimate the prevalence of anticholinergic use in England's older population in 1991 and 2011, and describe changes in use by participant's age, sex, cognition and disability. METHODS We compared data from participants aged 65+ years from the Cognitive Function and Ageing Studies (CFAS I and II), collected during 1990-1993 (N = 7635) and 2008-2011 (N = 7762). We estimated the prevalence of potent anticholinergic use (Anticholinergic Cognitive Burden [ACB] score = 3) and average anticholinergic burden (sum of ACB scores), using inverse probability weights standardised to the 2011 UK population. These were stratified by age, sex, Mini-Mental State Examination score, and activities of daily living (ADL) or instrumental ADL (IADL) disability. RESULTS Prevalence of potent anticholinergic use increased from 5.7% (95% Confidence Interval [CI] 5.2-6.3%) of the older population in 1990-93 to 9.9% (9.3-10.7%) in 2008-11, adjusted odds ratio of 1.90 (95% CI 1.67-2.16). People with clinically significant cognitive impairment (MMSE [Mini Mental State Examination] 21 or less) were the heaviest users of potent anticholinergics in CFAS II (16.5% [95% CI 12.0-22.3%]). Large increases in the prevalence of the use medication with 'any' anticholinergic activity were seen in older people with clinically significant cognitive impairment (53.3% in CFAS I to 71.5% in CFAS II). CONCLUSIONS Use of potent anticholinergic medications nearly doubled in England's older population over 20 years with some of the greatest increases amongst those particularly vulnerable to anticholinergic side-effects.
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Affiliation(s)
| | | | - George M Savva
- University of East Anglia, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Chris Fox
- University of East Anglia, Norwich, UK
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Improvement needed in the network geometry and inconsistency of Cochrane network meta-analyses: a cross-sectional survey. J Clin Epidemiol 2019; 113:214-227. [DOI: 10.1016/j.jclinepi.2019.05.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 05/09/2019] [Accepted: 05/22/2019] [Indexed: 12/21/2022]
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Andreas S, Röver C, Heinz J, Straube S, Watz H, Friede T. Decline of COPD exacerbations in clinical trials over two decades - a systematic review and meta-regression. Respir Res 2019; 20:186. [PMID: 31420040 PMCID: PMC6697937 DOI: 10.1186/s12931-019-1163-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/12/2019] [Indexed: 01/22/2023] Open
Abstract
Background An important goal of chronic obstructive pulmonary disease (COPD) treatment is to reduce the frequency of exacerbations. Some observations suggest a decline in exacerbation rates in clinical trials over time. A more systematic understanding would help to improve the design and interpretation of COPD trials. Methods We performed a systematic review and meta-regression of the placebo groups in published randomized controlled trials reporting exacerbations as an outcome. A Bayesian negative binomial model was developed to accommodate results that are reported in different formats; results are reported with credible intervals (CI) and posterior tail probabilities (pB). Results Of 1114 studies identified by our search, 55 were ultimately included. Exacerbation rates decreased by 6.7% (95% CI (4.4, 9.0); pB < 0.001) per year, or 50% (95% CI (36, 61)) per decade. Adjusting for available study and baseline characteristics such as forced expiratory volume in 1 s (FEV1) did not alter the observed trend considerably. Two subsets of studies, one using a true placebo group and the other allowing inhaled corticosteroids in the “placebo” group, also yielded consistent results. Conclusions In conclusion, this meta-regression indicates that the rate of COPD exacerbations decreased over the past two decades to a clinically relevant extent independent of important prognostic factors. This suggests that care is needed in the design of new trials or when comparing results from older trials with more recent ones. Also a considerable effect of adjunct therapy on COPD exacerbations can be assumed. Registration PROSPERO 2018 CRD4218118823. Electronic supplementary material The online version of this article (10.1186/s12931-019-1163-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefan Andreas
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany. .,Lung Clinic Immenhausen, Immenhausen, Germany.
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Judith Heinz
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Sebastian Straube
- Division of Preventive Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Heidelberg, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
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McCabe H, Godman B, Kurdi A, Johnston K, MacBride-Stewart S, Lennon J, Hurding S, Bennie M, Morton A. Prescribing trends of inhaler treatments for asthma and chronic obstructive pulmonary disease within a resource-constrained environment in the Scottish national health service: findings and implications. Expert Rev Respir Med 2019; 13:679-689. [PMID: 31189394 DOI: 10.1080/17476348.2019.1624528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: There is an increasing prevalence of asthma and chronic obstructive pulmonary disease (COPD) worldwide, leading to increased inhaler use. However, there are concerns with inhaler compliance resulting in different patented inhalers and longer-acting formulations. As a result, inhalers are now among the highest expenditure items in ambulatory care in Scotland leading to multiple initiatives to keep within budget without compromising care. Method: This study assesses inhaler utilization and expenditure between 2001 and 2017 alongside health authority initiatives. Results: There was an increase by 137% in inhaler utilization between 2001 and 2017, and a two-fold increase in expenditure, driven by the increasing use of patented combination inhalers to address concerns. This is very different to the oral markets where expenditure on proton pump inhibitors, statins, and antihypertensives have fallen considerably recently despite increased volumes due to the increasing use of low-cost generics. However, inhaler expenditure has started to fall with an increasing use of lower cost combinations and initiatives to reduce the steroid burden alongside monitoring patient care. Conclusion: Challenges with using and changing inhalers has meant this market has not followed other high-volume drug classes following patent loss. This is starting to change, with the situation monitored to enhance efficient prescribing alongside continued good quality care.
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Affiliation(s)
- Holly McCabe
- a Department of Management Science , Strathclyde Business School, University of Strathclyde , Glasgow , UK
| | - Brian Godman
- b Strathclyde Institute of Pharmacy and Biomedicial Sciences , University of Strathclyde , Glasgow , UK.,c Division of Clinical Pharmacology , Karolinska Institutet, Karolinska University Hospital , Huddinge , Sweden.,d Department of Public Health Pharmacy and Management , School of Pharmacy, Sefako Makgatho Health Sciences University , Garankuwa , South Africa
| | - Amanj Kurdi
- b Strathclyde Institute of Pharmacy and Biomedicial Sciences , University of Strathclyde , Glasgow , UK.,e Department of pharmacology , College of Pharmacy, Hawler Medical University , Erbil , Iraq
| | - Katie Johnston
- f Prescribing Advisor Primary Care , NHS , Edinburgh , UK
| | | | - Janey Lennon
- g Pharmacy Service , NHS Greater Glasgow and Clyde , Glasgow , UK
| | - Simon Hurding
- h Therapeutics Branch , Scottish Government , Edinburgh , UK
| | - Marion Bennie
- b Strathclyde Institute of Pharmacy and Biomedicial Sciences , University of Strathclyde , Glasgow , UK
| | - Alec Morton
- a Department of Management Science , Strathclyde Business School, University of Strathclyde , Glasgow , UK
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Affiliation(s)
- Surya P Bhatt
- 1 Division of Pulmonary, Allergy and Critical Care Medicine
- 2 UAB Lung Imaging Core, and
- 3 UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
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Thomas RM, Locke ER, Woo DM, Nguyen EHK, Press VG, Layouni TA, Trittschuh EH, Reiber GE, Fan VS. Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life. Respir Care 2017; 62:1412-1422. [PMID: 28720676 DOI: 10.4187/respcare.05445] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence. METHODS In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention. RESULTS A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, P = .01), fatigue (+0.6 points, P < .001), emotional function (+0.5 points, P = .001), and mastery (+0.7 points, P < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, P = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points (P < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 (P = .045). The pharmacist reported technical issues in 64% of visits. CONCLUSIONS Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.
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Affiliation(s)
- Rachel M Thomas
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Emily R Locke
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Deborah M Woo
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Ethan H K Nguyen
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Troy A Layouni
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Emily H Trittschuh
- Geriatric Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences
| | - Gayle E Reiber
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Vincent S Fan
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care.,Department of Medicine, University of Washington, Seattle, Washington
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12
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Miravitlles M, Soler-Cataluña JJ, Calle M, Molina J, Almagro P, Quintano JA, Trigueros JA, Cosío BG, Casanova C, Riesco JA, Simonet P, Rigau D, Soriano JB, Ancochea J. Spanish COPD Guidelines (GesEPOC) 2017. Pharmacological Treatment of Stable Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.arbr.2017.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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13
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Miravitlles M, Soler-Cataluña JJ, Calle M, Molina J, Almagro P, Quintano JA, Trigueros JA, Cosío BG, Casanova C, Antonio Riesco J, Simonet P, Rigau D, Soriano JB, Ancochea J. Spanish Guidelines for Management of Chronic Obstructive Pulmonary Disease (GesEPOC) 2017. Pharmacological Treatment of Stable Phase. Arch Bronconeumol 2017; 53:324-335. [PMID: 28477954 DOI: 10.1016/j.arbres.2017.03.018] [Citation(s) in RCA: 333] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 03/23/2017] [Accepted: 03/29/2017] [Indexed: 01/04/2023]
Abstract
The clinical presentation of chronic obstructive pulmonary disease (COPD) varies widely, so treatment must be tailored according to the level of risk and phenotype. In 2012, the Spanish COPD Guidelines (GesEPOC) first established pharmacological treatment regimens based on clinical phenotypes. These regimens were subsequently adopted by other national guidelines, and since then, have been backed up by new evidence. In this 2017 update, the original severity classification has been replaced by a much simpler risk classification (low or high risk), on the basis of lung function, dyspnea grade, and history of exacerbations, while determination of clinical phenotype is recommended only in high-risk patients. The same clinical phenotypes have been maintained: non-exacerbator, asthma-COPD overlap (ACO), exacerbator with emphysema, and exacerbator with bronchitis. Pharmacological treatment of COPD is based on bronchodilators, the only treatment recommended in low-risk patients. High-risk patients will receive different drugs in addition to bronchodilators, depending on their clinical phenotype. GesEPOC reflects a more individualized approach to COPD treatment, according to patient clinical characteristics and level of risk or complexity.
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Affiliation(s)
- Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), España.
| | | | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Jesús Molina
- Centro de Salud Francia, Dirección Asistencial Oeste, Madrid, España
| | - Pere Almagro
- Servicio de Medicina Interna, Hospital Universitario Mutua de Terrassa, Terrassa, España
| | | | | | - Borja G Cosío
- Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, España; CIBER de Enfermedades Respiratorias (CIBERES), España
| | - Ciro Casanova
- Servicio de Neumología-Unidad de Investigación, Hospital Universitario La Candelaria, Tenerife, España
| | | | - Pere Simonet
- Centro de Salud Viladecans-2, Dirección Atención Primaria Costa de Ponent-Institut Català de la Salut, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España
| | - David Rigau
- Centro Cochrane Iberoamericano, Barcelona, España
| | - Joan B Soriano
- Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Consultor Metodológico y de Investigación de SEPAR, Madrid, España
| | - Julio Ancochea
- Servicio de Neumología, Hospital Universitario de La Princesa, Instituto de Investigación, Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, España
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14
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Gulati S, Wells JM. Bringing Stability to the Chronic Obstructive Pulmonary Disease Patient: Clinical and Pharmacological Considerations for Frequent Exacerbators. Drugs 2017; 77:651-670. [PMID: 28255962 PMCID: PMC5396463 DOI: 10.1007/s40265-017-0713-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are critical events associated with an accelerated loss of lung function, increased morbidity, and excess mortality. AECOPD are heterogeneous in nature and this may directly impact clinical decision making, specifically in patients with frequent exacerbations. A 'frequent exacerbator' is a sub-phenotype of chronic obstructive pulmonary disease (COPD) and is defined as an individual who experiences two or more moderate-to-severe exacerbations per year. This distinct subgroup has higher mortality and accounts for more than half of COPD-related hospitalizations annually. Thus, it is imperative to identify individuals at risk for frequent exacerbations and choose optimal strategies to minimize risk for these events. New paradigms for using combination inhalers and the introduction of novel oral compounds provide expanded treatment options to reduce the risk and frequency of exacerbations. The goals of managing frequent exacerbators or patients at risk for AECOPD are: (1) maximizing bronchodilation; (2) reducing inflammation; and (3) targeting specific molecular pathways implicated in COPD and AECOPD pathogenesis. Novel inhaler therapies including combination long-acting muscarinic agents plus long-acting beta agonists show promising results compared with monotherapy or a long-acting beta agonist inhaled corticosteroid combination in reducing exacerbation risk among individuals at risk for exacerbations and among frequent exacerbators. Likewise, oral medications including macrolides and phosphodiesterase-4 inhibitors reduce the risk for AECOPD in select groups of individuals at high risk for exacerbation. Future direction in COPD management is based on the identification of various subtypes or 'endotypes' and targeting therapies based on their pathophysiology. This review describes the impact of AECOPD and the challenges posed by frequent exacerbators, and explores the rationale for different pharmacologic approaches to preventing AECOPD in these individuals.
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Affiliation(s)
- Swati Gulati
- Division of Pulmonary, Allergy and Critical Care, Lung Health Center, University of Alabama Birmingham, Birmingham, AL, USA
| | - J Michael Wells
- Division of Pulmonary, Allergy and Critical Care, Lung Health Center, University of Alabama Birmingham, Birmingham, AL, USA.
- Birmingham VA Medical Center, Birmingham, AL, USA.
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15
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Vemer P, Al MJ, Oppe M, Rutten-van Mölken MPMH. Mix and match. A simulation study on the impact of mixed-treatment comparison methods on health-economic outcomes. PLoS One 2017; 12:e0171292. [PMID: 28152099 PMCID: PMC5289594 DOI: 10.1371/journal.pone.0171292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 01/20/2017] [Indexed: 11/18/2022] Open
Abstract
Background Decision-analytic cost-effectiveness (CE) models combine many parameters, often obtained after meta-analysis. Aim We compared different methods of mixed-treatment comparison (MTC) to combine transition and event probabilities derived from several trials, especially with respect to health-economic (HE) outcomes like (quality adjusted) life years and costs. Methods Trials were drawn from a simulated reference population, comparing two of four fictitious interventions. The goal was to estimate the CE between two of these. The amount of heterogeneity between trials was varied in scenarios. Parameter estimates were combined using direct comparison, MTC methods proposed by Song and Puhan, and Bayesian generalized linear fixed effects (GLMFE) and random effects models (GLMRE). Parameters were entered into a Markov model. Parameters and HE outcomes were compared with the reference population using coverage, statistical power, bias and mean absolute deviation (MAD) as performance indicators. Each analytical step was repeated 1,000 times. Results The direct comparison was outperformed by the MTC methods on all indicators, Song’s method yielded low bias and MAD, but uncertainty was overestimated. Puhan’s method had low bias and MAD and did not overestimate uncertainty. GLMFE generally had the lowest bias and MAD, regardless of the amount of heterogeneity, but uncertainty was overestimated. GLMRE showed large bias and MAD and overestimated uncertainty. Song’s and Puhan’s methods lead to the least amount of uncertainty, reflected in the shape of the CE acceptability curve. GLMFE showed slightly more uncertainty. Conclusions Combining direct and indirect evidence is superior to using only direct evidence. Puhan’s method and GLMFE are preferred.
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Affiliation(s)
- Pepijn Vemer
- Institute for Medical Technology Assessment (iMTA), Erasmus University, Rotterdam, The Netherlands
- * E-mail:
| | - Maiwenn J. Al
- Institute for Medical Technology Assessment (iMTA), Erasmus University, Rotterdam, The Netherlands
| | - Mark Oppe
- Institute for Medical Technology Assessment (iMTA), Erasmus University, Rotterdam, The Netherlands
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16
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Guerra B, Gaveikaite V, Bianchi C, Puhan MA. Prediction models for exacerbations in patients with COPD. Eur Respir Rev 2017; 26:26/143/160061. [PMID: 28096287 DOI: 10.1183/16000617.0061-2016] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/25/2016] [Indexed: 11/05/2022] Open
Abstract
Personalised medicine aims to tailor medical decisions to the individual patient. A possible approach is to stratify patients according to the risk of adverse outcomes such as exacerbations in chronic obstructive pulmonary disease (COPD). Risk-stratified approaches are particularly attractive for drugs like inhaled corticosteroids or phosphodiesterase-4 inhibitors that reduce exacerbations but are associated with harms. However, it is currently not clear which models are best to predict exacerbations in patients with COPD. Therefore, our aim was to identify and critically appraise studies on models that predict exacerbations in COPD patients. Out of 1382 studies, 25 studies with 27 prediction models were included. The prediction models showed great heterogeneity in terms of number and type of predictors, time horizon, statistical methods and measures of prediction model performance. Only two out of 25 studies validated the developed model, and only one out of 27 models provided estimates of individual exacerbation risk, only three out of 27 prediction models used high-quality statistical approaches for model development and evaluation. Overall, none of the existing models fulfilled the requirements for risk-stratified treatment to personalise COPD care. A more harmonised approach to develop and validate high- quality prediction models is needed to move personalised COPD medicine forward.
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Affiliation(s)
- Beniamino Guerra
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Violeta Gaveikaite
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Camilla Bianchi
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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17
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The Impact of Excluding Trials from Network Meta-Analyses - An Empirical Study. PLoS One 2016; 11:e0165889. [PMID: 27926924 PMCID: PMC5142775 DOI: 10.1371/journal.pone.0165889] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 10/01/2016] [Indexed: 01/09/2023] Open
Abstract
Network meta-analysis (NMA) expands the scope of a conventional pairwise meta-analysis to simultaneously compare multiple treatments, which has an inherent appeal for clinicians, patients, and policy decision makers. Two recent reports have shown that the impact of excluding a treatment on NMAs can be substantial. However, no one has assessed the impact of excluding a trial from NMAs, which is important because many NMAs selectively include trials in the analysis. This article empirically examines the impact of trial exclusion using both the arm-based (AB) and contrast-based (CB) approaches, by reanalyzing 20 published NMAs involving 725 randomized controlled trials and 449,325 patients. For the population-averaged absolute risk estimates using the AB approach, the average fold changes across all networks ranged from 1.004 (with standard deviation 0.004) to 1.072 (with standard deviation 0.184); while the maximal fold changes ranged from 1.032 to 2.349. In 12 out of 20 NMAs, a 1.20-fold or larger change is observed in at least one of the population-averaged absolute risk estimates. In addition, while excluding a trial can substantially change the estimated relative effects (e.g., log odds ratios), there is no systematic difference in terms of changes between the two approaches. Changes in treatment rankings are observed in 7 networks and changes in inconsistency are observed in 3 networks. We do not observe correlations between changes in treatment effects, treatment rankings and inconsistency. Finally, we recommend rigorous inclusion and exclusion criteria, logical study selection process, and reasonable network geometry to ensure robustness and generalizability of the results of NMAs.
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18
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Abstract
Network meta-analysis of randomized controlled trials is increasingly used to combine both direct evidence comparing treatments within trials and indirect evidence comparing treatments across different trials. When the outcome is binary, the commonly used contrast-based network meta-analysis methods focus on relative treatment effects such as odds ratios comparing two treatments. As shown in a recent report, when using contrast-based network meta-analysis, the impact of excluding a treatment in the network can be substantial, suggesting a methodological limitation. In addition, relative treatment effects are sometimes not sufficient for patients to make decisions. For example, it can be challenging for patients to trade off efficacy and safety for two drugs if they only know the relative effects, not the absolute effects. A recently proposed arm-based network meta-analysis, based on a missing-data framework, provides an alternative approach. It focuses on estimating population-averaged treatment-specific absolute effects. This article examines the influence of treatment exclusion empirically using 14 published network meta-analyses, for both arm- and contrast-based approaches. The difference between these two approaches is substantial, and it is almost entirely due to single-arm trials. When a treatment is removed from a contrast-based network meta-analysis, it is necessary to exclude other treatments in two-arm studies that investigated the excluded treatment; such exclusions are not necessary in arm-based network meta-analysis, leading to substantial gain in performance.
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Affiliation(s)
- Lifeng Lin
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455
| | - Haitao Chu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455
| | - James S. Hodges
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455
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19
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Bhatt SP, Connett JE, Voelker H, Lindberg SM, Westfall E, Wells JM, Lazarus SC, Criner GJ, Dransfield MT. β-Blockers for the prevention of acute exacerbations of chronic obstructive pulmonary disease (βLOCK COPD): a randomised controlled study protocol. BMJ Open 2016; 6:e012292. [PMID: 27267111 PMCID: PMC4908863 DOI: 10.1136/bmjopen-2016-012292] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION A substantial majority of chronic obstructive pulmonary disease (COPD)-related morbidity, mortality and healthcare costs are due to acute exacerbations, but existing medications have only a modest effect on reducing their frequency, even when used in combination. Observational studies suggest β-blockers may reduce the risk of COPD exacerbations; thus, we will conduct a randomised, placebo-controlled trial to definitively assess the impact of metoprolol succinate on the rate of COPD exacerbations. METHODS AND ANALYSES This is a multicentre, placebo-controlled, double-blind, prospective randomised trial that will enrol 1028 patients with at least moderately severe COPD over a 3-year period. Participants with at least moderate COPD will be randomised in a 1:1 fashion to receive metoprolol or placebo; the cohort will be enriched for patients at high risk for exacerbations. Patients will be screened and then randomised over a 2-week period and will then undergo a dose titration period for the following 6 weeks. Thereafter, patients will be followed for 42 additional weeks on their target dose of metoprolol or placebo followed by a 4-week washout period. The primary end point is time to first occurrence of an acute exacerbation during the treatment period. Secondary end points include rates and severity of COPD exacerbations; rate of major cardiovascular events; all-cause mortality; lung function (forced expiratory volume in 1 s (FEV1)); dyspnoea; quality of life; exercise capacity; markers of cardiac stretch (pro-NT brain natriuretic peptide) and systemic inflammation (high-sensitivity C reactive protein and fibrinogen). Analyses will be performed on an intent-to-treat basis. ETHICS AND DISSEMINATION The study protocol has been approved by the Department of Defense Human Protection Research Office and will be approved by the institutional review board of all participating centres. Study findings will be disseminated through presentations at national and international conferences and publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02587351; Pre-results.
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Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John E Connett
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Helen Voelker
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah M Lindberg
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth Westfall
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - J Michael Wells
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Hospital, Birmingham, Alabama, USA
| | - Stephen C Lazarus
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Hospital, Birmingham, Alabama, USA
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20
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Crawley A, Laubscher T, Muddiman P, Kosar L. Pharmacologic management of COPD: Breadth of products for encouraging a breath of air. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:410-4. [PMID: 27255625 PMCID: PMC4865341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Alex Crawley
- Pharmacist for the RxFiles Academic Detailing Program.
| | - Tessa Laubscher
- Clinical Associate Professor of Academic Family Medicine at the University of Saskatchewan in Saskatoon
| | - Patricia Muddiman
- Practising family physician in Prince Albert, Sask, and Clinical Assistant Professor in the Department of Academic Family Medicine at the University of Saskatchewan
| | - Lynette Kosar
- Information Support Pharmacist for the RxFiles Academic Detailing Program
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21
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Crawley A, Laubscher T, Muddiman P, Kosar L. [Prise en charge pharmacologique de la BPCO: Un éventail de produits pour insuffler une bouffée d'air]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:e243-8. [PMID: 27255633 PMCID: PMC4865352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Alex Crawley
- Pharmacien pour le Programme de formation continue en pharmacothérapie RxFiles.
| | - Tessa Laubscher
- Professeure clinicienne agrégée de médecine familiale universitaire à l'Université de la Saskatchewan à Saskatoon
| | - Patricia Muddiman
- Médecin de famille en pratique à Prince Albert, en Saskatchewan, et professeure clinicienne adjointe au Département de médecine familiale universitaire de l'Université de la Saskatchewan
| | - Lynette Kosar
- Pharmacienne de soutien à l'information pour le Programme de formation continue en pharmacothérapie RxFiles
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22
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Roberts MH, Borrego ME, Kharat AA, Marshik PL, Mapel DW. Economic evaluations of fluticasone-propionate/salmeterol combination therapy for chronic obstructive pulmonary disease: a review of published studies. Expert Rev Pharmacoecon Outcomes Res 2016; 16:167-92. [PMID: 26839089 DOI: 10.1586/14737167.2016.1148602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This review identifies and evaluates the comprehensive reporting of peer-reviewed economic evaluations of the effectiveness of fluticasone-propionate/salmeterol combination (FSC) therapy for maintenance treatment of chronic obstructive pulmonary disease (COPD). Economic evaluations were included if published in English since 2003. Evaluation categories included in the review were cost-effectiveness, cost-utility, and cost-consequence analyses. FSC is cost-effective in comparison to short-acting bronchodilators (SABDs). Cost and outcome differences between FSC and other long-acting therapies were modest. Studies exhibited large variations in populations, designs and environment, limiting the ability to draw conclusions. Many new maintenance treatments for COPD have been approved since 2010. Most have yet to be compared to older treatments like FSC. Evaluations are needed that consider costs and outcomes from a societal perspective (e.g., patients' ability to keep working) and evaluations that include subgroup analyses to investigate differential impacts according to clusters of patient characteristics.
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Affiliation(s)
- M H Roberts
- a Department of Pharmacy Practice and Administrative Sciences , University of New Mexico College of Pharmacy , Albuquerque , NM , USA.,b LCF Research, Health Services Research Division , Albuquerque , NM , USA
| | - M E Borrego
- a Department of Pharmacy Practice and Administrative Sciences , University of New Mexico College of Pharmacy , Albuquerque , NM , USA
| | - A A Kharat
- a Department of Pharmacy Practice and Administrative Sciences , University of New Mexico College of Pharmacy , Albuquerque , NM , USA
| | - P L Marshik
- a Department of Pharmacy Practice and Administrative Sciences , University of New Mexico College of Pharmacy , Albuquerque , NM , USA
| | - D W Mapel
- b LCF Research, Health Services Research Division , Albuquerque , NM , USA
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23
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Tricco AC, Strifler L, Veroniki AA, Yazdi F, Khan PA, Scott A, Ng C, Antony J, Mrklas K, D'Souza J, Cardoso R, Straus SE. Comparative safety and effectiveness of long-acting inhaled agents for treating chronic obstructive pulmonary disease: a systematic review and network meta-analysis. BMJ Open 2015; 5:e009183. [PMID: 26503392 PMCID: PMC4636655 DOI: 10.1136/bmjopen-2015-009183] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare the safety and effectiveness of long-acting β-antagonists (LABA), long-acting antimuscarinic agents (LAMA) and inhaled corticosteroids (ICS) for managing chronic obstructive pulmonary disease (COPD). SETTING Systematic review and network meta-analysis (NMA). PARTICIPANTS 208 randomised clinical trials (RCTs) including 134,692 adults with COPD. INTERVENTIONS LABA, LAMA and/or ICS, alone or in combination, versus each other or placebo. PRIMARY AND SECONDARY OUTCOMES The proportion of patients with moderate-to-severe exacerbations. The number of patients experiencing mortality, pneumonia, serious arrhythmia and cardiovascular-related mortality (CVM) were secondary outcomes. RESULTS NMA was conducted including 20 RCTs for moderate-to-severe exacerbations for 26,141 patients with an exacerbation in the past year. 32 treatments were effective versus placebo including: tiotropium, budesonide/formoterol, salmeterol, indacaterol, fluticasone/salmeterol, indacaterol/glycopyrronium, tiotropium/fluticasone/salmeterol and tiotropium/budesonide/formoterol. Tiotropium/budesonide/formoterol was most effective (99.2% probability of being the most effective according to the Surface Under the Cumulative RAnking (SUCRA) curve). NMA was conducted on mortality (88 RCTs, 97 526 patients); fluticasone/salmeterol was more effective in reducing mortality than placebo, formoterol and fluticasone alone, and was the most effective (SUCRA=71%). NMA was conducted on CVM (37 RCTs, 55,156 patients) and the following were safest: salmeterol versus each OF placebo, tiotropium and tiotropium (Soft Mist Inhaler (SMR)); fluticasone versus tiotropium (SMR); and salmeterol/fluticasone versus tiotropium and tiotropium (SMR). Triamcinolone acetonide was the most harmful (SUCRA=81%). NMA was conducted on pneumonia occurrence (54 RCTs, 61 551 patients). 24 treatments were more harmful, including 2 that increased risk of pneumonia versus placebo; fluticasone and fluticasone/salmeterol. The most harmful agent was fluticasone/salmeterol (SUCRA=89%). NMA was conducted for arrhythmia; no statistically significant differences between agents were identified. CONCLUSIONS Many inhaled agents are available for COPD, some are safer and more effective than others. Our results can be used by patients and physicians to tailor administration of these agents. PROTOCOL REGISTRATION NUMBER PROSPERO # CRD42013006725.
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Affiliation(s)
- Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Strifler
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Areti-Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Fatemeh Yazdi
- Ottawa Hospital Research Institute, Center for Practice Changing Research Building, The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada
| | - Paul A Khan
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Alistair Scott
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Carmen Ng
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jesmin Antony
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kelly Mrklas
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Alberta Health Services, Edmonton, Alberta, Canada
| | - Jennifer D'Souza
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Roberta Cardoso
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Geriatric Medicine, University of Toronto, 27 Kings College Circle, Toronto, Ontario, Canada
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24
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Bhatt SP, Wells JM, Kinney GL, Washko GR, Budoff M, Kim YI, Bailey WC, Nath H, Hokanson JE, Silverman EK, Crapo J, Dransfield MT. β-Blockers are associated with a reduction in COPD exacerbations. Thorax 2015; 71:8-14. [PMID: 26283710 DOI: 10.1136/thoraxjnl-2015-207251] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/21/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND While some retrospective studies have suggested that β-blocker use in patients with COPD is associated with a reduction in the frequency of acute exacerbations and lower mortality, there is concern that their use in patients with severe COPD on home oxygen may be harmful. METHODS Subjects with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2-4 COPD participating in a prospective follow-up of the COPDGene cohort, a multicentre observational cohort of current and former smokers were recruited. Total and severe exacerbation rates were compared between groups categorised by β-blocker use on longitudinal follow-up using negative binomial regression analyses, after adjustment for demographics, airflow obstruction, %emphysema on CT, respiratory medications, presence of coronary artery disease, congestive heart failure and coronary artery calcification, and after adjustment for propensity to prescribe β-blockers. RESULTS 3464 subjects were included. During a median of 2.1 years of follow-up, β-blocker use was associated with a significantly lower rate of total (incidence risk ratio (IRR) 0.73, 95% CI 0.60 to 0.90; p=0.003) and severe exacerbations (IRR 0.67, 95% CI 0.48 to 0.93; p=0.016). In those with GOLD stage 3 and 4 and on home oxygen, use of β-blockers was again associated with a reduction in the rate of total (IRR 0.33, 95% CI 0.19 to 0.58; p<0.001) and severe exacerbations (IRR 0.35, 95% CI 0.16 to 0.76; p=0.008). Exacerbation reduction was greatest in GOLD stage B. There was no difference in all-cause mortality with β-blocker use. CONCLUSIONS β-Blockers are associated with a significant reduction in COPD exacerbations regardless of severity of airflow obstruction. The findings of this study should be tested in a randomised, placebo-controlled trial. TRIAL REGISTRATION NUMBER (ClinicalTrials.gov NCT00608764).
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Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James M Wells
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gregory L Kinney
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Budoff
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Young-Il Kim
- Department of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William C Bailey
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hrudaya Nath
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John E Hokanson
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edwin K Silverman
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Crapo
- Division of Pulmonary and Critical Care, National Jewish Health, Denver, Colorado, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA Birmingham VA Medical Center, Birmingham, Alabama, USA
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25
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Röver C, Andreas S, Friede T. Evidence synthesis for count distributions based on heterogeneous and incomplete aggregated data. Biom J 2015; 58:170-85. [DOI: 10.1002/bimj.201300288] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 11/19/2014] [Accepted: 02/15/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Christian Röver
- Department of Medical Statistics; University Medical Center Göttingen; Humboldtallee 32 37073 Göttingen Germany
| | - Stefan Andreas
- Lungenfachklinik Immenhausen; Robert-Koch-Straße 3 34376 Immenhausen Germany
- Clinics for Cardiology and Pulmonology; University Medical Center Göttingen; Robert-Koch-Straße 40 37099 Göttingen Germany
| | - Tim Friede
- Department of Medical Statistics; University Medical Center Göttingen; Humboldtallee 32 37073 Göttingen Germany
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26
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Wang G, Liu B, Cao Y, Du Y, Zhang H, Luo Q, Li B, Wu J, Lv Y, Sun J, Jin H, Wei K, Zhao Z, Kong L, Zhou X, Miao Q, Wang G, Zhou Q, Dong J. Effects of two Chinese herbal formulae for the treatment of moderate to severe stable chronic obstructive pulmonary disease: a multicenter, double-blind, randomized controlled trial. PLoS One 2014; 9:e103168. [PMID: 25118962 PMCID: PMC4132093 DOI: 10.1371/journal.pone.0103168] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/21/2014] [Indexed: 02/05/2023] Open
Abstract
Objective The study aims to evaluate the efficacy and safety of two Chinese herbal formulae for the treatment of stable COPD. Methods A multicenter, double-blind, double-dummy, and randomized controlled trial (RCT) was conducted. All groups were treated with additional conventional medicines. There were a 6-month treatment and a 12-month follow-up for 5 times. Primary outcomes included lung function test, exacerbation frequency, score of SGRQ. Second outcomes consisted of 6MWD, BODE index, psychological field score, inflammatory factors and cortisol. Results A total of 331 patients were randomly divided into two active treatment groups (Bushen Yiqi (BY) granule group, n = 109; Bushen Fangchuan (BF) tablet group, n = 109) and a placebo group (n = 113). Finally 262 patients completed the study. BY granule & BF tablet increased the values of VC, FEV1 (%) and FEV1/FVC (%), compared with placebo. BY granule improved PEF. Both treatments reduced acute exacerbation frequency (P = 0.067), BODE index and psychological field score, while improved 6MWD. In terms of descent rang of SGRQ score, both treatments increased (P = 0.01). Both treatments decreased inflammatory cytokines, such as IL-8, and IL-17(P = 0.0219). BY granule obviously descended IL-17(P<0.05), IL-1β (P = 0.05), IL-6, compared with placebo. They improved the level of IL-10 and cortisol. BY granule raised cortisol (P = 0.07) and decreased TNF-α. Both treatments slightly descended TGF-β1. In terms of safety, subject compliance and drug combination, there were no differences (P>0.05) among three groups. Conclusions BY granule and BF tablet were positively effective for the treatment of COPD, and the former performed better in general. Trial Registration Chinese Clinical Trial Register center ChiCTR-TRC-09000530
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Affiliation(s)
- Genfa Wang
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Baojun Liu
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Yuxue Cao
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Yijie Du
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Hongying Zhang
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Qingli Luo
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Bei Li
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Jinfeng Wu
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Yubao Lv
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Jing Sun
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Hualiang Jin
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Kai Wei
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Zhengxiao Zhao
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Lingwen Kong
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
| | - Xianmei Zhou
- Respiratory Department, Jiangsu Province Hospital of TCM, Nanjing University of TCM, Nanjing, PR China
| | - Qing Miao
- Respiratory Department, Xiyuan Hospital CACMS, Beijing, PR China
| | - Gang Wang
- Respiratory Department, West China Hospital, Sichuan University, Chengdu, PR China
| | - Qingwei Zhou
- Respiratory Department, the First Hospital Affiliated to Henan University of TCM, Zhengzhou, PR China
| | - Jingcheng Dong
- Department of integrated traditional Chinese and western medicine, Huashan Hospital, Fudan University, Shanghai, PR China
- Institute of integrated traditional Chinese and western medicine of Fudan University, Shanghai, PR China
- * E-mail:
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Abstract
This literature review updates the reader on the new studies regarding steroid therapy over the last year in stable COPD and in exacerbations. In stable COPD, we critique the 2011 update and 2013 revision of the GOLD guidelines, discuss why combining inhaled corticosteroids (ICS) with long-acting beta-agonists (LABA) (ICS/LABA) is preferable over LABA alone and review the literature for intraclass differences, finding that the evidence does not clearly support superiority of any particular ICS/LABA. We also address other comparisons against ICS/LABA, including triple therapy. We briefly review which type of inhaler should be chosen. For exacerbations, we report the REDUCE trial findings favouring a 5-day course of systemic steroids, and other trials addressing which steroid and route to use, including in an intensive care setting. Lastly, the future lies in new anti-inflammatories and re-phenotyping the heterogeneous amalgamation of COPD. A Spanish guideline recommends distinguishing steroid-responsive eosinophilic exacerbators from other phenotypes.
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Affiliation(s)
- Daan A De Coster
- Department of Primary Care and Population Health, University College London, Upper 3rd Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, UK NW3 2PF
| | - Melvyn Jones
- Department of Primary Care and Population Health, University College London, Upper 3rd Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, UK NW3 2PF
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Blanchette CM, Gross NJ, Altman P. Rising Costs of COPD and the Potential for Maintenance Therapy to Slow the Trend. AMERICAN HEALTH & DRUG BENEFITS 2014; 7:98-106. [PMID: 24991394 PMCID: PMC4049119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) affects an estimated 14% of adults in the United States between the ages of 40 and 79 years. This progressive disease is characterized by persistent airflow limitation. The management of patients with COPD is focused on reducing risk factors, relieving symptoms, and preventing exacerbations. OBJECTIVE To examine the peer-reviewed literature on the impact of maintenance therapy on the direct treatment costs of patients with COPD in the United States. METHODS PubMed was searched for articles written in English that were published between 2000 and 2013, using the search terms "COPD," "economics," "exacerbation," "maintenance," and related terms. Articles reporting the results of longitudinal studies of the costs associated with the management of patients with COPD, the costs associated with hospitalizations for acute exacerbations of COPD, and randomized clinical trials evaluating the effects of maintenance therapy on the incidence of COPD exacerbations were included in this review. RESULTS The search identified a total of 277 articles, and 11 of these articles were deemed appropriate for inclusion in this review. The direct healthcare costs for patients with COPD increased by 38% between 1987 and 2007, and continued to increase by approximately 5% annually between 2006 and 2009. The costs associated with hospital admissions for patients with COPD accounted for the largest absolute increase ($2289 per admission in constant 2007 US dollars). Recent estimates suggest that the aggregate costs associated with the treatment of acute exacerbations are between $3.2 billion and $3.8 billion, and that annual healthcare costs are 10-fold greater for patients with COPD associated with acute exacerbations than for patients with COPD but without exacerbations. The results of 2 large clinical trials of maintenance therapy, including a long-acting cholinergic antagonist or a long-acting beta-2 agonist, showed a 16% to 17% reduction in the incidence of exacerbations compared with placebo. Nevertheless, maintenance therapy remains underutilized, with only 30% to 35% of patients with COPD in private and public health insurance plans receiving prescriptions for maintenance therapy. CONCLUSIONS The treatment of acute exacerbations of COPD remains the major driver of increasing healthcare costs associated with this condition. The appropriate use of maintenance therapy has been shown to reduce the incidence of exacerbations and has the potential to reduce overall costs associated with the management of patients with COPD.
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Affiliation(s)
- Christopher M Blanchette
- Research Associate Professor, Department of Public Health Sciences, College of Health & Human Services, University of North Carolina at Charlotte, and Director, Health Economics & Outcomes Research, Otsuka America Pharmaceutical, Inc, Charlotte, NC
| | - Nicholas J Gross
- President and CEO, University Medical Research, LLC, Farmington, CT
| | - Pablo Altman
- Medical Director, Medical Affairs, Mylan Specialty LP, Basking Ridge, NJ, at the time of writing
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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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Cope S, Donohue JF, Jansen JP, Kraemer M, Capkun-Niggli G, Baldwin M, Buckley F, Ellis A, Jones P. Comparative efficacy of long-acting bronchodilators for COPD: a network meta-analysis. Respir Res 2013; 14:100. [PMID: 24093477 PMCID: PMC4014806 DOI: 10.1186/1465-9921-14-100] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/25/2013] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Clinicians are faced with an increasingly difficult choice regarding the optimal bronchodilator for patients with chronic obstructive pulmonary disease (COPD) given the number of new treatments. The objective of this study is to evaluate the comparative efficacy of indacaterol 75/150/300 μg once daily (OD), glycopyrronium bromide 50 μg OD, tiotropium bromide 18 μg/5 μg OD, salmeterol 50 μg twice daily (BID), formoterol 12 μg BID, and placebo for moderate to severe COPD. METHODS Forty randomized controlled trials were combined in a Bayesian network meta-analysis. Outcomes of interest were trough and post-dose forced expiratory volume in 1 second (FEV1), St. George's Respiratory Questionnaire (SGRQ) score and responders (≥4 points), and Transition Dyspnea Index (TDI) score and responders (≥1 point) at 6 months. RESULTS Indacaterol was associated with a higher trough FEV1 than other active treatments (difference for indacaterol 150 μg and 300 μg versus placebo: 152 mL (95% credible interval (CrI): 126, 179); 160 mL (95% CrI: 133, 187)) and the greatest improvement in SGRQ score (difference for indacaterol 150 μg and 300 μg versus placebo: -3.9 (95% CrI -5.2, -2.6); -3.6 (95% CrI -4.8, -2.3)). Glycopyrronium and tiotropium 18 μg resulted in the next best estimates for both outcomes with minor differences (difference for glycopyrronium versus tiotropium for trough FEV1 and SGRQ: 18 mL (95% CrI: -16, 51); -0.55 (95% CrI: -2.04, 0.92). CONCLUSION In terms of trough FEV1 and SGRQ score indacaterol, glycopyrronium, and tiotropium are expected to be the most effective bronchodilators.
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Affiliation(s)
| | - James F Donohue
- Department of Medicine, University North Carolina, North Carolina, USA
| | | | | | | | | | | | | | - Paul Jones
- Division of Clinical Science, St George’s University of London, London SW17 0RE, UK
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López-Campos JL, Calero Acuña C. What is in the guidelines about the pharmacological treatment of chronic obstructive pulmonary disease? Expert Rev Respir Med 2013; 7:43-51. [PMID: 23551023 DOI: 10.1586/ers.13.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
With the publication of the new guidelines (The Global Initiative for Chronic Obstructive Lung Disease 2011 and Guía Española de la COPD) on chronic obstructive pulmonary disease (COPD), the pharmacological treatment of this disease has changed substantially. In this article, the evidence supporting the use of pharmacological groups in COPD is summarized and the place of each of these drugs among the new therapeutic strategies is established. Although short-acting bronchodilators have been used as maintenance therapy for COPD for many years, few clinical trials are available on the efficacy and safety of these agents, whose role was defined at the very early stages of treatment. The introduction of long-acting bronchodilators, administered every 12 or 24 h, led to an increase in therapeutic effects and an improvement in both treatment adherence and dosage; therefore, both guidelines consider these drugs as the standard therapy for all types of patients and clinical phenotypes. The combination of long-acting bronchodilators from different families has been established as a new therapeutic approach for patients with persistent symptoms despite an appropriate bronchodilator treatment. Anti-inflammatory therapy with inhaled corticosteroids has been discussed at length, and is considered in the current guidelines as the treatment of choice in patients with a high risk of exacerbations associated with an impaired lung function or previous exacerbations, or presenting with phenotypes that are susceptible to the effect of corticosteroids. Roflumilast is a novel drug with a clearly defined indication. Finally, further evidence about other therapies, such as antibiotics or mucolytics, is emerging that will help define their appropriate use in selected patients. At present, pharmacological management of COPD is being re-evaluated. As long as we are able to apply the new treatment approaches to the clinical reality of our patients we will achieve greater benefits in both the short and the long term with a reduction in potential complications.
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Affiliation(s)
- José Luis López-Campos
- Medical Surgical Unit of Respiratory Diseases, Biomedicine Institute of Seville (IBiS), Virgen del Rocío University Hospital, Seville, Spain.
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Cazzola M, Bardaro F, Stirpe E. The role of indacaterol for chronic obstructive pulmonary disease (COPD). J Thorac Dis 2013; 5:559-66. [PMID: 23991316 DOI: 10.3978/j.issn.2072-1439.2013.07.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 07/26/2013] [Indexed: 11/14/2022]
Abstract
Indacaterol is the first long-acting β2-agonist (LABAs) approved for the treatment of chronic obstructive pulmonary disease (COPD) that allows for once-daily (OD) administration. It is rapidly acting, with an onset of action in 5 minutes, like salbutamol and formoterol but with a sustained bronchodilator effect, that last for 24 hours, like tiotropium. In long-term clinical studies (12 weeks to 1 year) in patients with moderate to severe COPD, OD indacaterol 150 or 300 μg improved lung function (primary endpoint) significantly more than placebo, and improvements were significantly greater than twice-daily formoterol 12 μg or salmeterol 50 μg, and noninferior to OD tiotropium bromide 18 μg. Indacaterol was well tolerated at all doses and with a good overall safety profile. Cost-utility analyses show that indacaterol 150 μg has lower total costs and better outcomes than tiotropium and salmeterol. These findings suggest that indacaterol can be considered a first choice drug in the treatment of the patient with mild/moderate stable COPD. However, in people with COPD who remain symptomatic on treatment with indacaterol, adding a long-acting muscarinic antagonist (LAMA) is the preferable option. In any case, it is advisable to combine indacaterol with a OD inhaled corticosteroid (ICS), such as mometasone furoate or ciclesonide, in patients with low FEV1, and, in those patients who have many symptoms and a high risk of exacerbations, to combine it with a LAMA and a OD ICS.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Clinical Pharmacology, Department of System Medicine, University of Rome "Tor Vergata", Rome, Italy
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33
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Vemer P, Al MJ, Oppe M, Rutten-van Mölken MPMH. A choice that matters? Smulation study on the impact of direct meta-analysis methods on health economic outcomes. PHARMACOECONOMICS 2013; 31:719-730. [PMID: 23736971 DOI: 10.1007/s40273-013-0067-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Decision-analytic cost-effectiveness (CE) models combine many different parameters like transition probabilities, event probabilities, utilities and costs, which are often obtained after meta-analysis. The method of meta-analysis may affect the CE estimate. AIM Our aim was to perform a simulation study that compares the performance of different methods of meta-analysis, especially with respect to model-based health economic (HE) outcomes. METHODS A reference patient population of 50,000 was simulated from which sets of samples were drawn. Each sample drawn represented a clinical trial comparing two fictitious interventions. In several scenarios, the heterogeneity between these trials was varied, by drawing one or more of the trials from predefined subpopulations. Parameter estimates from these trials were combined using frequentist fixed (FFE) and random effects (FRE), and Bayesian fixed (BFE) and random effects (BRE) meta-analysis. The pooled parameter estimates were entered into a probabilistic cost-effectiveness Markov model. The four methods of meta-analysis resulted in different parameter estimates and HE outcomes, which were compared with the true values in the reference population. Performance statistics were: (1) the percentage of repetitions that the confidence interval of the probabilistic sensitivity analysis covers the true value (coverage), (2) the difference between the estimated and true value (bias), (3) the mean absolute value of the bias (MAD) and (4) the percentage of repetitions that result in a statistically significant difference between the two interventions (statistical power). As the differences between methods could be due to chance, we repeated every step of the analysis 1,000 times to study whether differences were systematic. RESULTS FFE, FRE and BFE lead to different parameter estimates, but, when entered into the model, they do not lead to large differences in the point estimates of the HE outcomes, even in scenarios where we built in heterogeneity. Random effects methods do not necessarily reduce bias when heterogeneity is added to the trials, and may even increase bias in certain situations. BRE tends to overestimate uncertainty reflected in the CE acceptability curve. CONCLUSION FFE, FRE and BFE lead to comparable HE outcomes. BRE tends to overestimate uncertainty. Based on this study, we recommend FRE as the preferred method of meta-analysis.
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Affiliation(s)
- Pepijn Vemer
- Institute for Medical Technology Assessment (iMTA), Erasmus University, PO Box 1738, 3000 DR, Rotterdam, The Netherlands.
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34
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Dalbak LG, Rognstad S, Melbye H, Straand J. Changed terms for drug payment influenced GPs' diagnoses and prescribing practice for inhaled corticosteroids. Eur J Gen Pract 2013; 19:106-10. [PMID: 23560809 PMCID: PMC3696339 DOI: 10.3109/13814788.2013.766713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 01/02/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inhaled glucocorticosteroids (ICS) are first-line anti-inflammatory treatment in asthma, but not in chronic obstructive pulmonary disease (COPD). To restrict ICS use in COPD to cases of severe disease, new terms for reimbursement of drug costs were introduced in Norway in 2006, requiring a diagnosis of COPD to be verified by spirometry. OBJECTIVES To describe how GPs' diagnoses and treatment of patients who used ICS before 2006 changed after a reassessment of the patients that included spirometry. METHODS From the shared electronic patient record system in one group practice, patients ≥ 50 years prescribed ICS (including in combination with long-acting beta2-agonists) during the previous year were identified and invited to a tailored consultation including spirometry to assure the quality of diagnosis and treatment. GPs' diagnoses and ICS prescribing patterns after this reassessment were recorded, retrospectively. RESULTS Of 164 patients identified, 112 were included. Post-bronchodilator spirometry showed airflow limitation indicating COPD in 55 patients. Of the 57 remaining patients, five had a positive reversibility test. The number of patients diagnosed with asthma increased (from 25 to 62) after the reassessment. A diagnosis of COPD was also more frequently used, whereas fewer patients had other pulmonary diagnoses. ICS was discontinued in 31 patients; 20 with mild to moderate COPD and 11 with normal spirometry. CONCLUSION Altered reimbursement terms for ICS changed GPs' diagnostic practice in a way that made the diagnoses better fit with the treatment given, but over-diagnosis of asthma could not be excluded. Spirometry was useful for identifying ICS overuse.
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Affiliation(s)
- Lene G Dalbak
- Department of General Practice, Institute of Health and Society, University of Oslo, 0318 Oslo, Norway.
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36
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Consenso sobre atención integral de las agudizaciones de la enfermedad pulmonar obstructiva crónica (ATINA-EPOC). Parte VI. Semergen 2013; 39:85-8. [DOI: 10.1016/j.semerg.2012.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 03/15/2012] [Indexed: 11/19/2022]
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Veroniki AA, Vasiliadis HS, Higgins JPT, Salanti G. Evaluation of inconsistency in networks of interventions. Int J Epidemiol 2013; 42:332-45. [PMID: 23508418 PMCID: PMC5411010 DOI: 10.1093/ije/dys222] [Citation(s) in RCA: 384] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The assumption of consistency, defined as agreement between direct and indirect sources of evidence, underlies the increasingly popular method of network meta-analysis. No evidence exists so far regarding the extent of inconsistency in full networks of interventions or the factors that control its statistical detection. METHODS In this paper we assess the prevalence of inconsistency from data of 40 published networks of interventions involving 303 loops of evidence. Inconsistency is evaluated in each loop by contrasting direct and indirect estimates and by employing an omnibus test of consistency for the entire network. We explore whether different effect measures for dichotomous outcomes are associated with differences in inconsistency, and evaluate whether different ways to estimate heterogeneity affect the magnitude and detection of inconsistency. RESULTS Inconsistency was detected in from 2% to 9% of the tested loops, depending on the effect measure and heterogeneity estimation method. Loops that included comparisons informed by a single study were more likely to show inconsistency. About one-eighth of the networks were found to be inconsistent. The proportions of inconsistent loops do not materially change when different effect measures are used. Important heterogeneity or the overestimation of heterogeneity was associated with a small decrease in the prevalence of statistical inconsistency. CONCLUSIONS The study suggests that changing the effect measure might improve statistical consistency, and that an analysis of sensitivity to the assumptions and an estimator of heterogeneity might be needed before reaching a conclusion about the absence of statistical inconsistency, particularly in networks with few studies.
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Affiliation(s)
- Areti Angeliki Veroniki
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
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Yu T, Vollenweider D, Varadhan R, Li T, Boyd C, Puhan MA. Support of personalized medicine through risk-stratified treatment recommendations - an environmental scan of clinical practice guidelines. BMC Med 2013; 11:7. [PMID: 23302096 PMCID: PMC3565912 DOI: 10.1186/1741-7015-11-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 01/09/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Risk-stratified treatment recommendations facilitate treatment decision-making that balances patient-specific risks and preferences. It is unclear if and how such recommendations are developed in clinical practice guidelines (CPGs). Our aim was to assess if and how CPGs develop risk-stratified treatment recommendations for the prevention or treatment of common chronic diseases. METHODS We searched the United States National Guideline Clearinghouse for US, Canadian and National Institute for Health and Clinical Excellence (United Kingdom) CPGs for heart disease, stroke, cancer, chronic obstructive pulmonary disease and diabetes that make risk-stratified treatment recommendations. We included only those CPGs that made risk-stratified treatment recommendations based on risk assessment tools. Two reviewers independently identified CPGs and extracted information on recommended risk assessment tools; type of evidence about treatment benefits and harms; methods for linking risk estimates to treatment evidence and for developing treatment thresholds; and consideration of patient preferences. RESULTS We identified 20 CPGs that made risk-stratified treatment recommendations out of 133 CPGs that made any type of treatment recommendations for the chronic diseases considered in this study. Of the included 20 CPGs, 16 (80%) used evidence about treatment benefits from randomized controlled trials, meta-analyses or other guidelines, and the source of evidence was unclear in the remaining four (20%) CPGs. Nine CPGs (45%) used evidence on harms from randomized controlled trials or observational studies, while 11 CPGs (55%) did not clearly refer to harms. Nine CPGs (45%) explained how risk prediction and evidence about treatments effects were linked (for example, applying estimates of relative risk reductions to absolute risks), but only one CPG (5%) assessed benefit and harm quantitatively and three CPGs (15%) explicitly reported consideration of patient preferences. CONCLUSIONS Only a small proportion of CPGs for chronic diseases make risk-stratified treatment recommendations with a focus on heart disease and stroke prevention, diabetes and breast cancer. For most CPGs it is unclear how risk-stratified treatment recommendations were developed. As a consequence, it is uncertain if CPGs support patients and physicians in finding an acceptable benefit- harm balance that reflects both profile-specific outcome risks and preferences.
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Affiliation(s)
- Tsung Yu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Daniela Vollenweider
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Ravi Varadhan
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Tianjing Li
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Cynthia Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Milo A Puhan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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Mackay AJ, Hurst JR. COPD exacerbations: causes, prevention, and treatment. Immunol Allergy Clin North Am 2012; 33:95-115. [PMID: 23337067 DOI: 10.1016/j.iac.2012.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The mechanisms of chronic obstructive pulmonary disease exacerbation are complex. Respiratory viruses (in particular rhinovirus) and bacteria play a major role in the cause of these events. A distinct group of patients seems susceptible to frequent exacerbations, irrespective of disease severity, and this phenotype is stable over time. Many current therapeutic strategies help reduce exacerbation frequency. Further work is required to develop novel anti-inflammatory therapies for exacerbation prevention and treatment. This article focuses on the cause of chronic obstructive pulmonary disease exacerbations, and the current preventative and acute interventions available.
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Affiliation(s)
- Alex J Mackay
- Academic Unit of Respiratory Medicine, Royal Free Campus, UCL Medical School, Rowland Hill Street, London NW3 2PF, UK.
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Serrano-Mollar A. [Alveolar epithelial cell injury as an etiopathogenic factor in pulmonary fibrosis]. Arch Bronconeumol 2012; 48 Suppl 2:2-6. [PMID: 23116901 PMCID: PMC7131261 DOI: 10.1016/s0300-2896(12)70044-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Idiopathic pulmonary fibrosis (IPF) is characterized by a progressive accumulation of extracellular matrix and an imbalance between profibrotic and antifibrotic mediators. In the last few years, understanding of the mechanisms of the biology of IPF has increased. One of the most significant discoveries is the finding that alveolar epithelial cell injury plays an important role in the pathogenesis of this disease. In this review, we describe some of the mechanisms involved in alveolar cell injury and their contribution to the development of IPF.
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Affiliation(s)
- Anna Serrano-Mollar
- Departamento de Patología Experimental, Institut d'Investigacions Biomèdiques de Barcelona, España.
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Riemsma R, Forbes CA, Amonkar MM, Lykopoulos K, Diaz JR, Kleijnen J, Rea DW. Systematic review of lapatinib in combination with letrozole compared with other first-line treatments for hormone receptor positive(HR+) and HER2+ advanced or metastatic breast cancer(MBC). Curr Med Res Opin 2012; 28:1263-79. [PMID: 22738819 DOI: 10.1185/03007995.2012.707643] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Third-generation aromatase inhibitors (letrozole, anastrozole) have shown superior efficacy in early and advanced breast cancer compared with tamoxifen. For HR+, HER2+ MBC, combination of an AI with an anti-HER2 agent (lapatinib or trastuzumab) has shown clinical benefit. METHODS Six databases were searched until January 2009 for randomized controlled clinical trials, assessing the safety and efficacy of first-line treatments for postmenopausal women with HR+ and HER2 (ErbB2) positive MBC, who have not received prior therapy for advanced or metastatic disease. Relevant interventions were lapatinib, aromatase inhibitors, tamoxifen, and trastuzumab. Outcomes included overall survival (OS), progression-free-survival (PFS), time-to-progression (TTP), and objective response rate (ORR). RESULTS Eighteen studies (62 papers) were included. Lapatinib + letrozole was significantly superior to letrozole alone based on a direct head-to-head study in terms of PFS/TTP and ORR. Using a network meta-analysis, compared with lapatinib + letrozole, tamoxifen (HR = 0.45 (95% CI: 0.32, 0.65) and anastrozole (HR = 0.53 (0.36, 0.80)) scored significantly worse in terms of PFS/TTP and ORR (tamoxifen: OR = 0.25 (0.12, 0.53), anastrozole: OR = 0.27 (0.12, 0.58). The combination also seemed significantly superior to exemestane in terms of PFS/TTP (HR = 0.52 (0.34, 0.79)). Lapatinib + letrozole also seemed better, although not significantly, in terms of OS versus tamoxifen: HR = 0.74 (0.49, 1.12), anastrozole: HR = 0.71 (0.45, 1.14) and exemestane: HR = 0.65 (0.39, 1.11). When compared with trastuzumab + anastrozole, lapatinib + letrozole seemed to be better in terms of OS (HR = 0.85 (0.47, 1.54)), PFS/TTP (HR = 0.89 (0.54, 1.47)) and ORR (OR = 0.92 (0.24, 3.48)), although, none of these results were significant. DISCUSSION Lapatinib + letrozole was significantly superior to letrozole in terms of PFS/TTP and ORR based on a direct head-to-head study. Indirect comparisons appeared to favor lapatinib + letrozole versus other first-line treatments used in this patient population in terms of three main outcomes: OS, PFS/TTP and ORR. Indirect comparison results are based on a network analysis for which the basic assumptions of homogeneity, similarity and consistency were not fulfilled. Therefore, despite the fact that these are the best available data, the results need to be interpreted with caution.
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Miravitlles M, Soler-Cataluña JJ, Calle M, Molina J, Almagro P, Quintano JA, Riesco JA, Trigueros JA, Piñera P, Simón A, López-Campos JL, Soriano JB, Ancochea J. [Spanish COPD Guidelines (GesEPOC): Pharmacological treatment of stable COPD]. Aten Primaria 2012; 44:425-37. [PMID: 22704760 PMCID: PMC7025253 DOI: 10.1016/j.aprim.2012.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022] Open
Abstract
Recognizing the clinical heterogeneity of COPD suggests a specific therapeutic approach directed by the so-called clinical phenotypes of the disease. The Spanish COPD Guidelines (GesEPOC) is an initiative of SEPAR, which, together with the scientific societies involved in COPD patient care, and the Spanish Patient Forum, has developed these new clinical practice guidelines. This present article describes the severity classification and the pharmacological treatment of stable COPD. GesEPOC identifies four clinical phenotypes with differential treatment: non-exacerbator, mixed COPD-asthma, exacerbator with emphysema and exacerbator with chronic bronchitis. Pharmacological treatment of COPD is based on bronchodilation in addition to other drugs depending on the clinical phenotype and severity. Severity is established by the BODE/BODEx multidimensional scales. Severity can also be approximated by assessing airflow obstruction, dyspnea, level of physical activity and history of exacerbations. GesEPOC is a new, more individualized approach to COPD treatment according to the clinical characteristics of the patients.
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Affiliation(s)
- Marc Miravitlles
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Barcelona, Spain.
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Miravitlles M, Soler-Cataluña JJ, Calle M, Molina J, Almagro P, Quintano JA, Riesco JA, Trigueros JA, Piñera P, Simón A, López-Campos JL, Soriano JB, Ancochea J. Spanish COPD Guidelines (GesEPOC): Pharmacological Treatment of Stable COPD. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.arbr.2012.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
The mechanisms of COPD exacerbation are complex. Respiratory viruses (in particular rhinovirus) and bacteria play a major role in the causative etiology of COPD exacerbations. In some patients, noninfective environmental factors may also be important. Data recently published from a large observational study identified a phenotype of patients more susceptible to frequent exacerbations. Many current therapeutic strategies can reduce exacerbation frequency. Future studies may target the frequent exacerbator phenotype, or those patients colonized with potential bacterial pathogens, for such therapies as long-term antibiotics, thus preventing exacerbations by decreasing bacterial load or preventing new strain acquisition in the stable state. Respiratory viral infections are also an important therapeutic target for COPD. Further work is required to develop new anti-inflammatory agents for exacerbation prevention, and novel acute treatments to improve outcomes at exacerbation.
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Affiliation(s)
- Alex J Mackay
- Academic Unit of Respiratory Medicine, Royal Free Campus, UCL Medical School, London, UK.
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Cope S, Zhang J, Williams J, Jansen JP. Efficacy of once-daily indacaterol 75 μg relative to alternative bronchodilators in COPD: a study level and a patient level network meta-analysis. BMC Pulm Med 2012; 12:29. [PMID: 22732017 PMCID: PMC3512498 DOI: 10.1186/1471-2466-12-29] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 06/25/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The objective of this study was to evaluate the comparative efficacy of indacaterol 75 μg once daily (OD), tiotropium 18 μg OD, salmeterol 50 μg twice daily (BID), formoterol 12 μg BID, and placebo for the treatment of chronic obstructive pulmonary disease (COPD) based on individual patient data (IPD) from randomized controlled trials (RCTs) from the indacaterol trial program and aggregate data (AD) identified from a systematic review of RCTs. METHODS 22 RCTs were included in the AD analysis that evaluated: indacaterol 75 μg (n = 2 studies), indacaterol 150 μg n = 5 (i.e. salmeterol 50 μg) (n = 5), indacaterol 300 μg (n = 2), tiotropium 18 μg (n = 10), salmeterol 50 μg (n = 7), and formoterol 12 μg (n = 4). All of the studies except for one head-to-head comparison (tiotropium vs. salmeterol) were placebo controlled. Outcomes of interest were trough forced expiratory volume in 1 second (FEV1) and St. George's Respiratory Questionnaire (SGRQ) total score at week 12. The AD from all trials was analysed simultaneously using a Bayesian network meta-analysis (NMA) and relative treatment effects between all regimens were obtained. In a separate analysis, the IPD available from the 6 indacaterol RCTs was analysed in a NMA. Treatment-by-covariate interactions were included in both analyses to improve similarity of the trials. RESULTS All interventions compared were more efficacious than placebo regarding FEV1 at 12 weeks. Indacaterol 75 μg is expected to result in a comparable FEV1 at 12 weeks to tiotropium and salmeterol based on both IPD and AD analyses. In comparison to formoterol, the IPD and AD results indicate indacaterol 75 μg is more efficacious (IPD = 0.07 L difference; 95%Credible Interval (CrI) 0.02 to 0.11; AD = 0.05 L difference; 95%CrI 0.01; 0.09). In terms of SGRQ total score at 12 weeks, indacaterol 75 μg and formoterol were more efficacious than placebo, whereas for tiotropium and salmeterol the credible intervals included zero for the AD results only (tiotropium: -2.99 points improvement versus placebo; 95%CrI -6.48 to 0.43; salmeterol:-2.52; 95%CrI: -5.34; 0.44). Both IPD and AD results suggest that indacaterol 75 μg is expected to be comparable to all active treatments. CONCLUSIONS Based on a synthesis of currently available AD RCT evidence as well as an IPD network meta-analysis of six RCTs, indacaterol 75 μg is expected to be at least as efficacious as formoterol and comparable to tiotropium and salmeterol regarding FEV1. Furthermore, indacaterol 75 μg shows comparable level of improvement in health-related quality of life to tiotropium, salmeterol, and formoterol, as measured by the SGRQ.
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Affiliation(s)
| | - Jie Zhang
- Novartis Pharmaceuticals, Skillman, NJ, USA
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Spanish COPD Guidelines (GesEPOC): pharmacological treatment of stable COPD. Spanish Society of Pulmonology and Thoracic Surgery. Arch Bronconeumol 2012; 48:247-57. [PMID: 22561012 DOI: 10.1016/j.arbres.2012.04.001] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 04/11/2012] [Indexed: 12/14/2022]
Abstract
Recognizing the clinical heterogeneity of COPD suggests a specific therapeutic approach directed by the so-called clinical phenotypes of the disease. The Spanish COPD Guidelines (GesEPOC) is an initiative of SEPAR, which, together with the scientific societies involved in COPD patient care, and the Spanish Patient Forum, has developed these new clinical practice guidelines. This present article describes the severity classification and the pharmacological treatment of stable COPD. GesEPOC identifies four clinical phenotypes with differential treatment: non-exacerbator, mixed COPD-asthma, exacerbator with emphysema and exacerbator with chronic bronchitis. Pharmacological treatment of COPD is based on bronchodilation in addition to other drugs depending on the clinical phenotype and severity. Severity is established by the BODE/BODEx multidimensional scales. Severity can also be approximated by assessing airflow obstruction, dyspnea, level of physical activity and history of exacerbations. GesEPOC is a new, more individualized approach to COPD treatment according to the clinical characteristics of the patients.
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Wolff RF, Aune D, Truyers C, Hernandez AV, Misso K, Riemsma R, Kleijnen J. Systematic review of efficacy and safety of buprenorphine versus fentanyl or morphine in patients with chronic moderate to severe pain. Curr Med Res Opin 2012; 28:833-45. [PMID: 22443154 DOI: 10.1185/03007995.2012.678938] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To systematically assess efficacy and safety of buprenorphine patch versus fentanyl patch in patients with chronic moderate to severe pain. METHODS Fifteen databases were searched up to December 2010. Randomised and quasi-randomised trials assessing the efficacy in patients with chronic pain were included. Quantitative methods for data synthesis were used and two network meta-analyses were conducted. RESULTS Fourteen unique trials (17 publications) were included. No head-to-head randomised trials of buprenorphine patch compared with fentanyl patch were identified. Therefore, less robust evidence from indirect comparisons was used. Results from a network meta-analysis of non-enriched designs (eight trials), using trials versus placebo and trials versus morphine for indirect comparisons, indicated that transdermal fentanyl, in comparison with transdermal buprenorphine, showed significantly more nausea (odds ratio [OR] 4.66, 95% confidence interval (CI) 1.07 to 20.39), a significantly higher number of treatment discontinuations due to adverse events (OR 5.94, 95% CI 1.78 to 19.87), and non-significant differences on all other outcomes, including pain measures. In comparison with morphine, transdermal buprenorphine had a significantly higher decrease of pain intensity (MD [mean difference] -16.20, 95% CI -28.92 to -3.48) while morphine caused more cases of constipation (OR 7.50, 95% CI 1.45 to 38.85) and a significantly higher number of treatment discontinuations due to adverse events (OR 5.80, 95% CI 1.68 to 20.11). All other outcomes showed non-significant differences between transdermal buprenorphine and morphine. The results were similar when also including six trials using enriched designs with the exception of more cases of vomiting for fentanyl (OR 17.32, 95% CI 4.43 to 67.71) and morphine (OR 15.85, 95% CI 3.92 to 64.13) compared to buprenorphine. CONCLUSIONS The findings indicate comparability of transdermal buprenorphine and transdermal fentanyl for pain measures with significantly fewer adverse events (nausea and treatment discontinuation due to adverse events) caused by transdermal buprenorphine.
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Cope S, Capkun-Niggli G, Gale R, Lassen C, Owen R, Ouwens MJNM, Bergman G, Jansen JP. Efficacy of once-daily indacaterol relative to alternative bronchodilators in COPD: a patient-level mixed treatment comparison. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:524-533. [PMID: 22583463 DOI: 10.1016/j.jval.2012.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 12/05/2011] [Accepted: 01/24/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Indacaterol was evaluated versus placebo, formoterol, and salmeterol in randomized controlled trials. No direct comparisons, however, are available for indacaterol 150 μg with formoterol or indacaterol 300 μg with salmeterol. Indacaterol trial evidence was synthesized to provide coherent estimates of indacaterol 150 μg and indacaterol 300 μg relative to formoterol, salmeterol, and tiotropium. METHODS Four randomized controlled trials were combined with Bayesian mixed treatment comparisons by using individual patient-level data. End points of interest were trough forced expiratory volume in 1 second (FEV(1)), St. George's Respiratory Questionnaire (SGRQ) total score and response (≥ 4 points), and Transition Dyspnea Index total score and response (≥ 1 point). RESULTS Indacaterol 150 μg demonstrated a higher FEV(1) than did formoterol at 12 weeks and 6 months (0.10 L difference; 95% credible interval [CrI] = 0.06-0.14), as did indacaterol 300 μg versus salmeterol (0.06 L difference at 12 weeks; CrI = 0.02-0.10; 0.06 L at 6 months; CrI = 0.02-0.11). Regarding SGRQ, indacaterol 150 μg demonstrated a comparable proportion of responders versus formoterol, as did indacaterol 300 μg versus salmeterol. In comparison to tiotropium, indacaterol 150 μg demonstrated a greater proportion of responders (odds ratio = 1.52 at 12 weeks; CrI 1.15-2.00). For Transition Dyspnea Index, indacaterol 150 μg and formoterol showed a similar response. Indacaterol 300 μg was more efficacious than salmeterol (odds ratio = 1.65 at 12 weeks; CrI 1.16-2.34). Overall, indacaterol 150 μg showed the greatest efficacy for SGRQ and indacaterol 300 μg for FEV(1) and Transition Dyspnea Index. CONCLUSION Indacaterol is expected to be comparable to formoterol, salmeterol, and tiotropium, providing higher FEV(1) than formoterol and salmeterol and greater improvement in the SGRQ total score than tiotropium. Indacaterol 150 μg provided comparable improvement in dyspnea, while indacaterol 300 μg demonstrated the greatest response overall.
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Thorlund K, Mills E. Stability of additive treatment effects in multiple treatment comparison meta-analysis: a simulation study. Clin Epidemiol 2012; 4:75-85. [PMID: 22570567 PMCID: PMC3346206 DOI: 10.2147/clep.s29470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Many medical interventions are administered in the form of treatment combinations involving two or more individual drugs (eg, drug A + drug B). When the individual drugs and drug combinations have been compared in a number of randomized clinical trials, it is possible to quantify the comparative effectiveness of all drugs simultaneously in a multiple treatment comparison (MTC) meta-analysis. However, current MTC models ignore the dependence between drug combinations (eg, A + B) and the individual drugs that are part of the combination. In particular, current models ignore the possibility that drug effects may be additive, ie, the property that the effect of A and B combined is equal to the sum of the individual effects of A and B. Current MTC models may thus be suboptimal for analyzing data including drug combinations when their effects are additive or approximately additive. However, the extent to which the additivity assumption can be violated before the conventional model becomes the more optimal approach is unknown. The objective of this study was to evaluate the comparative statistical performance of the conventional MTC model and the additive effects MTC model in MTC scenarios where additivity holds true, is mildly violated, or is strongly violated. Methods We simulated MTC scenarios in which additivity held true, was mildly violated, or was strongly violated. For each scenario we simulated 500 MTC data sets and applied the conventional and additive effects MTC models in a Bayesian framework. Under each scenario we estimated the proportion of treatment effect estimates that were 20% larger than ‘the truth’ (ie, % overestimates), the proportion that were 20% smaller than ‘the truth’ (ie, % underestimates), the coverage of the 95% credible intervals, and the statistical power. We did this for all the comparisons under both models. Results Under true additivity, the additive effects model is superior to the conventional model. Under mildly violated additivity, the additive model generally yields more overestimates or underestimates for a subset of treatment comparisons, but comparable coverage and greater power. Under strongly violated additivity, the proportion of overestimates or underestimates and coverage is considerably worse with the additive effects model. Conclusion The additive MTC model is statistically superior when additivity holds true. The two models are comparably advantageous in terms of a bias-precision trade-off when additivity is only mildly violated. When additivity is strongly violated, the additive effects model is statistically inferior.
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Affiliation(s)
- Kristian Thorlund
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton
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Postma D, Anzueto A, Calverley P, Jenkins C, Make BJ, Sciurba FC, Similowski T, van der Molen T, Eriksson G. A new perspective on optimal care for patients with COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2011; 20:205-9. [PMID: 21559550 DOI: 10.4104/pcrj.2011.00041] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Worldwide, clinicians face the task of providing millions of patients with the best possible treatment and management of COPD. Currently, management primarily involves short-term 'here-and-now' goals, targeting immediate patient benefit. However, although there is considerable knowledge available to assist clinicians in minimising the current impact of COPD on patients, relatively little is known about which dominant factors predict future risks. These predictors may vary for different outcomes, such as exacerbations, mortality, co-morbidities, and the long-term consequences of COPD. We propose a new paradigm to achieve 'optimal COPD care' based on the concept that here-and-now goals should be integrated with goals to improve long-term outcomes and reduce future risks. Whilst knowledge on risk factors for poorer outcomes in COPD is growing and some data exist on positive effects of pharmacological interventions, information on defining the benefits of all commonly used interventions for reducing the risk of various future disease outcomes is still scarce. Greater insight is needed into the relationships between the two pillars of optimal COPD care: 'best current control' and 'future risk reduction'. This broader approach to disease management should result in improved care for every COPD patient now and into the future.
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Affiliation(s)
- Dirkje Postma
- Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, University of Groningen, The Netherlands.
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