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Soler-Cataluña JJ, Huerta A, Almagro P, González-Segura D, Cosío BG. Lack of Clinical Control in COPD Patients Depending on the Target and the Therapeutic Option. Int J Chron Obstruct Pulmon Dis 2023; 18:1367-1376. [PMID: 37434953 PMCID: PMC10332360 DOI: 10.2147/copd.s414910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction According to the Global Initiative for chronic obstructive lung disease (GOLD), when a treatment is not achieving an appropriate response it should be switched taking into account the predominant treatable trait to target (dyspnea or exacerbations). The objective of the present study was to investigate the lack of clinical control according to the target and medication groups. Materials and Methods This was a post-hoc analysis of the CLAVE study, an observational, cross-sectional, multicenter study which evaluated the clinical control, and related-factors, in a cohort of 4801 patients with severe chronic obstructive pulmonary disease (COPD). The primary endpoint was the percentage of uncontrolled patients defined as COPD Assessment Test (CAT) >16 or presence of exacerbations in the last 3 months despite receiving long-acting beta2-agonist (LABA) and/or long-acting antimuscarinic antagonist (LAMA) with or without inhaled corticosteroids (ICS). Secondary objectives included the description of sociodemographic and clinical characteristics of patients by therapeutic group and the identification of characteristics potentially associated with the lack of control of COPD including low adherence measured by the test to adherence to inhalers (TAI). Results In the dyspnea pathway, lack of clinical control was of 25.0% of patients receiving LABA or LAMA in monotherapy, 29.5% by those with LABA + LAMA, 38.3% with LABA + ICS and 37.0% with triple therapy (LABA + LAMA + ICS). In the exacerbation pathway, percentages were 87.1%, 76.7%, 83.3%, and 84.1%, respectively. Low physical activity and high Charlson comorbidity index were independent factor of non-control in all therapeutic groups. Additional factors were lower post-bronchodilator FEV1 and poor adherence to inhalers. Conclusion There are still room for improvement in COPD control. From the pharmacological perspective, every step in treatment have a pool of uncontrolled patients in which a step-up could be considered according to a trait to target strategy.
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Affiliation(s)
- Juan José Soler-Cataluña
- Department of Pneumology, Hospital Arnau de Vilanova-Lliria, Valencia, Spain
- Medicine Department, València University and CIBERES, Valencia, Spain
| | - Arturo Huerta
- Pulmonary and Critical Care Division, Clínica Sagrada Família, Barcelona, Spain
| | - Pere Almagro
- Internal Medicine Department, Mutua Terrassa University Hospital, Terrassa, Spain
| | | | - Borja G Cosío
- Department of Pneumology, H. Universitari Son Espases Hospital-IdISBa and CIBERES, Palma de Mallorca, Spain
| | - On behalf of the CLAVE Study Investigators
- Department of Pneumology, Hospital Arnau de Vilanova-Lliria, Valencia, Spain
- Medicine Department, València University and CIBERES, Valencia, Spain
- Pulmonary and Critical Care Division, Clínica Sagrada Família, Barcelona, Spain
- Internal Medicine Department, Mutua Terrassa University Hospital, Terrassa, Spain
- Medical Advisor, Chiesi SAU, Barcelona, Spain
- Department of Pneumology, H. Universitari Son Espases Hospital-IdISBa and CIBERES, Palma de Mallorca, Spain
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2
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Macdonald DM, Palzer EF, Abbasi A, Baldomero AK, Bhatt SP, Casaburi R, Connett JE, Dransfield MT, Gaeckle NT, Mkorombindo T, Rossiter HB, Stringer WW, Tiller NB, Wendt CH, Zhao D, Kunisaki KM. Chronotropic index during 6-minute walk and acute respiratory events in COPDGene. Respir Med 2022; 194:106775. [PMID: 35203009 PMCID: PMC8932051 DOI: 10.1016/j.rmed.2022.106775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/04/2022] [Accepted: 02/13/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Lower heart rate (HR) increases during exercise and slower HR recovery (HRR) after exercise are markers of worse autonomic function that may be associated with risk of acute respiratory events (ARE). METHODS Data from 6-min walk testing (6MWT) in COPDGene were used to calculate the chronotropic index (CI) [(HR immediately post 6MWT - resting HR)/((220 - age) - resting HR)] and HRR at 1 min after 6MWT completion. We used zero-inflated negative binomial regression to test associations of CI and HRR with rates of any ARE (requiring steroids and/or antibiotics) and severe ARE (requiring emergency department visit or hospitalization), among all participants and in spirometry subgroups (normal, chronic obstructive pulmonary disease [COPD], and preserved ratio with impaired spirometry). RESULTS Among 4,484 participants, mean follow-up time was 4.1 years, and 1,966 had COPD. Among all participants, CI-6MWT was not associated with rate of any ARE [adjusted incidence rate ratio (aIRR) 0.98 (0.95-1.01)], but higher CI-6MWT was associated with lower rate of severe ARE [0.95 (0.92-0.99)]. Higher HRR was associated with a lower rate of both any ARE [0.97 (0.95-0.99)] and severe ARE [0.95 (0.92-0.98)]. Results were similar in the COPD spirometry subgroup. CONCLUSION Heart rate measures derived from 6MWT tests may have utility in predicting risk of acute respiratory events and COPD exacerbations.
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Affiliation(s)
- David M Macdonald
- Pulmonary Section, Minneapolis VA, Minneapolis, MN, USA; Division of Pulmonary, Allergy, Critical Care, and Sleep, University of Minnesota, Minneapolis, MN, USA.
| | - Elise F Palzer
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Asghar Abbasi
- Division of Respiratory & Critical Care, Physiology & Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Arianne K Baldomero
- Pulmonary Section, Minneapolis VA, Minneapolis, MN, USA; Division of Pulmonary, Allergy, Critical Care, and Sleep, University of Minnesota, Minneapolis, MN, USA
| | - Surya P Bhatt
- Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard Casaburi
- Division of Respiratory & Critical Care, Physiology & Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - John E Connett
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Mark T Dransfield
- Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nathaniel T Gaeckle
- Division of Pulmonary, Allergy, Critical Care, and Sleep, University of Minnesota, Minneapolis, MN, USA
| | | | - Harry B Rossiter
- Division of Respiratory & Critical Care, Physiology & Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - William W Stringer
- Division of Respiratory & Critical Care, Physiology & Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nicholas B Tiller
- Division of Respiratory & Critical Care, Physiology & Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Chris H Wendt
- Pulmonary Section, Minneapolis VA, Minneapolis, MN, USA; Division of Pulmonary, Allergy, Critical Care, and Sleep, University of Minnesota, Minneapolis, MN, USA
| | - Dongxing Zhao
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Ken M Kunisaki
- Pulmonary Section, Minneapolis VA, Minneapolis, MN, USA; Division of Pulmonary, Allergy, Critical Care, and Sleep, University of Minnesota, Minneapolis, MN, USA
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3
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Calle Rubio M, Rodriguez Hermosa JL, de Torres JP, Marín JM, Martínez-González C, Fuster A, Cosío BG, Peces-Barba G, Solanes I, Feu-Collado N, Lopez-Campos JL, Casanova C. COPD Clinical Control: predictors and long-term follow-up of the CHAIN cohort. Respir Res 2021; 22:36. [PMID: 33541356 PMCID: PMC7863480 DOI: 10.1186/s12931-021-01633-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background Control in COPD is a dynamic concept that can reflect changes in patients’ clinical status that may have prognostic implications, but there is no information about changes in control status and its long-term consequences. Methods We classified 798 patients with COPD from the CHAIN cohort as controlled/uncontrolled at baseline and over 5 years. We describe the changes in control status in patients over long-term follow-up and analyze the factors that were associated with longitudinal control patterns and related survival using the Cox hazard analysis. Results 134 patients (16.8%) were considered persistently controlled, 248 (31.1%) persistently uncontrolled and 416 (52.1%) changed control status during follow-up. The variables significantly associated with persistent control were not requiring triple therapy at baseline and having a better quality of life. Annual changes in outcomes (health status, psychological status, airflow limitation) did not differ in patients, regardless of clinical control status. All-cause mortality was lower in persistently controlled patients (5.5% versus 19.1%, p = 0.001). The hazard ratio for all-cause mortality was 2.274 (95% CI 1.394–3.708; p = 0.001). Regarding pharmacological treatment, triple inhaled therapy was the most common option in persistently uncontrolled patients (72.2%). Patients with persistent disease control more frequently used bronchodilators for monotherapy (53%) at recruitment, although by the end of the follow-up period, 20% had scaled up their treatment, with triple therapy being the most frequent therapeutic pattern. Conclusions The evaluation of COPD control status provides relevant prognostic information on survival. There is important variability in clinical control status and only a small proportion of the patients had persistently good control. Changes in the treatment pattern may be relevant in the longitudinal pattern of COPD clinical control. Further studies in other populations should validate our results. Trial registration: Clinical Trials.gov: identifier NCT01122758.
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Affiliation(s)
- Myriam Calle Rubio
- Pulmonology Department, Hospital Clínico San Carlos, C/ Martin Lagos S/N, 28040, Madrid, Spain.,Medical Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Juan Luis Rodriguez Hermosa
- Pulmonology Department, Hospital Clínico San Carlos, C/ Martin Lagos S/N, 28040, Madrid, Spain. .,Medical Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| | - Juan P de Torres
- Respirology and Sleep Division, Queen's University, Kingston, ON, Canada
| | - José María Marín
- Respiratory Department. Hospital, Universitario Miguel Servet and IISAragón, Ciber Enfermedades Respiratorias, Madrid, Spain
| | - Cristina Martínez-González
- Pulmonology Department, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - Antonia Fuster
- Pulmonology Department, Hospital Universitario Son Llàtzer, Palma de Mallorca, Spain
| | - Borja G Cosío
- Department of Respiratory Medicine, Hospital Universitario Son Espases-IdISBa and CIBERES, Palma de Mallorca, Spain
| | - Germán Peces-Barba
- Pulmonology Department, IIS-Fundación Jiménez Díaz-CIBERES, Madrid, Spain
| | - Ingrid Solanes
- Pulmonology Department, Hospital de La Santa Creu Y San Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Nuria Feu-Collado
- Pulmonology Department, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocio, Universidad de Sevilla, CIBERES, Seville, Spain
| | - Ciro Casanova
- Pulmonology Department, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, Tenerife, Spain
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Baldomero AK, Wendt CH, Petersen A, Gaeckle NT, Han MK, Kunisaki KM. Impact of gastroesophageal reflux on longitudinal lung function and quantitative computed tomography in the COPDGene cohort. Respir Res 2020; 21:203. [PMID: 32746820 PMCID: PMC7397645 DOI: 10.1186/s12931-020-01469-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 07/24/2020] [Indexed: 12/14/2022] Open
Abstract
Rationale Gastroesophageal reflux disease (GERD) is a common comorbidity in chronic obstructive pulmonary disease (COPD) and has been associated with increased risk of acute exacerbations, hospitalization, emergency room visits, costs, and quality-of-life impairment. However, it remains unclear whether GERD contributes to the progression of COPD as measured by lung function or computed tomography. Objective To determine the impact of GERD on longitudinal changes in lung function and radiographic lung disease in the COPDGene cohort. Methods We evaluated 5728 participants in the COPDGene cohort who completed Phase I (baseline) and Phase II (5-year follow-up) visits. GERD status was based on participant-reported physician diagnoses. We evaluated associations between GERD and annualized changes in lung function [forced expired volume in 1 s (FEV1) and forced vital capacity (FVC)] and quantitative computed tomography (QCT) metrics of airway disease and emphysema using multivariable regression models. These associations were further evaluated in the setting of GERD treatment with proton-pump inhibitors (PPI) and/or histamine-receptor 2 blockers (H2 blockers). Results GERD was reported by 2101 (36.7%) participants at either Phase I and/or Phase II. GERD was not associated with significant differences in slopes of FEV1 (difference of − 2.53 mL/year; 95% confidence interval (CI), − 5.43 to 0.37) or FVC (difference of − 3.05 mL/year; 95% CI, − 7.29 to 1.19), but the odds of rapid FEV1 decline of ≥40 mL/year was higher in those with GERD (adjusted odds ratio (OR) 1.20; 95%CI, 1.07 to 1.35). Participants with GERD had increased progression of QCT-measured air trapping (0.159%/year; 95% CI, 0.054 to 0.264), but not other QCT metrics such as airway wall area/thickness or emphysema. Among those with GERD, use of PPI and/or H2 blockers was associated with faster decline in FEV1 (difference of − 6.61 mL/year; 95% CI, − 11.9 to − 1.36) and FVC (difference of − 9.26 mL/year; 95% CI, − 17.2 to − 1.28). Conclusions GERD was associated with faster COPD disease progression as measured by rapid FEV1 decline and QCT-measured air trapping, but not by slopes of lung function. The magnitude of the differences was clinically small, but given the high prevalence of GERD, further investigation is warranted to understand the potential disease-modifying role of GERD in COPD pathogenesis and progression. Clinical trials registration NCT00608764.
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Affiliation(s)
- Arianne K Baldomero
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, One Veterans Drive, Mailstop: Pulmonary 111N, Minneapolis, MN, 55417, USA. .,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Chris H Wendt
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, One Veterans Drive, Mailstop: Pulmonary 111N, Minneapolis, MN, 55417, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ashley Petersen
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Nathaniel T Gaeckle
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ken M Kunisaki
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, One Veterans Drive, Mailstop: Pulmonary 111N, Minneapolis, MN, 55417, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
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5
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Hersh CP, Zacharia S, Prakash Arivu Chelvan R, Hayden LP, Mirtar A, Zarei S, Putcha N. Immunoglobulin E as a Biomarker for the Overlap of Atopic Asthma and Chronic Obstructive Pulmonary Disease. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 7:1-12. [PMID: 31999898 DOI: 10.15326/jcopdf.7.1.2019.0138] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Asthma-COPD overlap (ACO) is a common clinical syndrome, yet there is no single objective definition. We hypothesized that immunoglobulin E (IgE) measurements could be used to refine the definition of ACO. In baseline plasma samples from 2870 participants in the COPD Genetic Epidemiology (COPDGene®) study, we measured total IgE levels and specific IgE levels to 6 common allergens. Compared to usual chronic obstructive pulmonary disease (COPD), participants with ACO (based on self-report of asthma) had higher total IgE levels (median 67.0 versus 42.2 IU/ml) and more frequently had at least one positive specific IgE (43.5% versus 24.5%). We previously used a strict definition of ACO in participants with COPD, based on self-report of a doctor's diagnosis of asthma before age 40. This strict ACO definition was refined by the presence of atopy, determined by total IgE > 100 IU/ml or at least one positive specific IgE, as was the broader definition of ACO based on self-reported asthma history. Participants with all 3 ACO definitions were younger (mean age 60.0-61.3 years), were more commonly African American (36.8%-44.2%), had a higher exacerbation frequency (1.0-1.2 in the past year), and had more airway wall thickening on quantitative analysis of chest computed tomography (CT) scans. Among participants with ACO, 37%-46% did not have atopy; these individuals had more emphysema on chest CT scan. Based on associations with exacerbations and CT airway disease, IgE did not clearly improve the clinical definition of ACO. However, IgE measurements could be used to subdivide individuals with atopic and non-atopic ACO, who might have different biologic mechanisms and potential treatments.
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Affiliation(s)
- Craig P Hersh
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Soumya Zacharia
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Lystra P Hayden
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Sara Zarei
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Arasila Biotech, San Diego, California
| | - Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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Maselli DJ, Bhatt SP, Anzueto A, Bowler RP, DeMeo DL, Diaz AA, Dransfield MT, Fawzy A, Foreman MG, Hanania NA, Hersh CP, Kim V, Kinney GL, Putcha N, Wan ES, Wells JM, Westney GE, Young KA, Silverman EK, Han MK, Make BJ. Clinical Epidemiology of COPD: Insights From 10 Years of the COPDGene Study. Chest 2019; 156:228-238. [PMID: 31154041 PMCID: PMC7198872 DOI: 10.1016/j.chest.2019.04.135] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/08/2019] [Accepted: 04/28/2019] [Indexed: 12/16/2022] Open
Abstract
The Genetic Epidemiology of COPD (COPDGene) study is a noninterventional, multicenter, longitudinal analysis of > 10,000 subjects, including smokers with a ≥ 10 pack-year history with and without COPD and healthy never smokers. The goal was to characterize disease-related phenotypes and explore associations with susceptibility genes. The subjects were extensively phenotyped with the use of comprehensive symptom and comorbidity questionnaires, spirometry, CT scans of the chest, and genetic and biomarker profiling. The objective of this review was to summarize the major advances in the clinical epidemiology of COPD from the first 10 years of the COPDGene study. We highlight the influence of age, sex, and race on the natural history of COPD, and the impact of comorbid conditions, chronic bronchitis, exacerbations, and asthma/COPD overlap.
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Affiliation(s)
- Diego J Maselli
- Division of Pulmonary Diseases and Critical Care, UT Health San Antonio, and South Texas Veterans Health System, San Antonio, TX
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care, UT Health San Antonio, and South Texas Veterans Health System, San Antonio, TX
| | - Russell P Bowler
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Dawn L DeMeo
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alejandro A Diaz
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Ashraf Fawzy
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marilyn G Foreman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Craig P Hersh
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine, Philadelphia, PA
| | - Gregory L Kinney
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | - Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily S Wan
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; VA Boston Healthcare System, Jamaica Plain, MA
| | - J Michael Wells
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Gloria E Westney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Kendra A Young
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | - Edwin K Silverman
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Barry J Make
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
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7
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Morros R, Vedia C, Giner-Soriano M, Casellas A, Amado E, Baena JM. [Community-acquired pneumonia in patients with chronic obstructive pulmonary disease treated with inhaled corticosteroids or other bronchodilators. Study PNEUMOCORT]. Aten Primaria 2018; 51:333-340. [PMID: 29661670 PMCID: PMC6837040 DOI: 10.1016/j.aprim.2018.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 01/17/2018] [Accepted: 02/09/2018] [Indexed: 01/15/2023] Open
Abstract
Objetivos Analizar el riesgo de neumonía y/o exacerbaciones en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) tratados con corticoides inhalados (CI) y no tratados con CI (NCI). Estimar el riesgo de neumonía según la dosis de CI. Diseño Estudio de cohortes de base poblacional. Emplazamiento Atención Primaria. Institut Català de la Salut. Participantes Pacientes ≥ 45 años diagnosticados de EPOC entre 2007 y 2009 en el Sistema de Información para el Desarrollo de la Investigación en Atención Primaria (SIDIAP). Intervención Dos cohortes; pacientes que inician CI y pacientes que inician broncodilatadores NCI después del diagnóstico de EPOC. Mediciones principales Sociodemográficas, tabaquismo, antecedentes patológicos, neumonías, exacerbaciones, vacunaciones y tratamientos farmacológicos. Resultados Se incluyeron 3.837 pacientes: el 58% en el grupo CI y el 42% en el grupo NCI. Se detectaron incidencias superiores de neumonía y exacerbaciones en el grupo CI respecto al NCI (2,18 vs. 1,37). El riesgo de neumonía y de exacerbaciones graves no fue significativamente diferente entre grupos: HR de 1,17 (IC 95%: 0,87-1,56) y de 1,06 (IC 95%: 0,87-1,31), respectivamente. En el grupo CI presentaron mayor riesgo de exacerbaciones leves, con HR de 1,28 (IC 95%: 1,10-1,50). Las variables asociadas a mayor riesgo de neumonías fueron: edad, diabetes, neumonías y bronquitis previas, EPOC muy grave, tratamiento con β2-adrenérgicos o anticolinérgicos a dosis bajas, y tratamiento previo con corticoides orales. Conclusiones No hubo diferencias entre cohortes en el riesgo de NAC ni exacerbaciones graves. Las exacerbaciones leves fueron superiores en el grupo CI. Tanto NAC como exacerbaciones graves fueron más frecuentes en pacientes con EPOC grave y en pacientes tratados con dosis altas de CI.
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Affiliation(s)
- Rosa Morros
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España; Institut Català de la Salut, Generalitat de Catalunya, Barcelona, España
| | - Cristina Vedia
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España; Unitat de Farmàcia, Servei d'Atenció Primària Barcelonès Nord i Maresme, Institut Català de la Salut, Badalona, España.
| | - Maria Giner-Soriano
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España; Institut Català de la Salut, Generalitat de Catalunya, Barcelona, España
| | - Aina Casellas
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, España
| | - Ester Amado
- Àmbit d'Atenció Barcelona Ciutat, Institut Català de la Salut, Barcelona, España
| | - Jose Miguel Baena
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Centre de Salut la Marina, Institut Català de la Salut, Barcelona, España
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8
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Miravitlles M, Sliwinski P, Rhee CK, Costello RW, Carter V, Tan J, Lapperre TS, Alcazar B, Gouder C, Esquinas C, García-Rivero JL, Kemppinen A, Tee A, Roman-Rodríguez M, Soler-Cataluña JJ, Price DB. Evaluation of criteria for clinical control in a prospective, international, multicenter study of patients with COPD. Respir Med 2018; 136:8-14. [DOI: 10.1016/j.rmed.2018.01.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 01/11/2018] [Accepted: 01/29/2018] [Indexed: 01/31/2023]
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Bigatao AM, Herbella FAM, Del Grande LM, Nascimento OA, Jardim JR, Patti MG. Chronic Obstructive Pulmonary Disease Exacerbations Are Influenced by Gastroesophageal Reflux Disease. Am Surg 2018. [DOI: 10.1177/000313481808400122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Gastroesophageal reflux disease (GERD) is associated with different pulmonary diseases, including chronic obstructive pulmonary disease (COPD). Whether GERD is contributory to COPD severity remains unclear. This study aims to evaluate the contribution of GERD to the clinical manifestation of COPD based on ventilatory parameters and yearly clinical exacerbations. We studied 48 patients (56% females, age 66 years) with COPD. All patients underwent high-resolution manometry and esophageal pH monitoring. The patients were separated into two groups according to the presence of GERD. GERD was present in 21 (44%) patients. GERD + and GERD – groups did not differ in regard to gender, age, and body mass index. Pulmonary parameters were not different in the absence or presence of GERD. The number of yearly exacerbations was higher in patients GERD1. The severity of GERD (as measured by DeMeester score) correlated with the number of exacerbations. Our results show the following: 1) GERD does not influence pulmonary parameters and 2) GERD is associated with a higher number of annual clinical exacerbations. We believe GERD must be objectively tested in patients with COPD because the prevalence of GERD in these patients is underestimated when only symptoms are considered. GERD treatment might decrease the frequency of episodes of exacerbation.
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Affiliation(s)
- Amilcar M. Bigatao
- Department of Medicine, Respiratory Division, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A. M. Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Leonardo M. Del Grande
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Oliver A. Nascimento
- Department of Medicine, Respiratory Division, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Jose R. Jardim
- Department of Medicine, Respiratory Division, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G. Patti
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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10
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Calverley PMA, Tetzlaff K, Dusser D, Wise RA, Mueller A, Metzdorf N, Anzueto A. Determinants of exacerbation risk in patients with COPD in the TIOSPIR study. Int J Chron Obstruct Pulmon Dis 2017; 12:3391-3405. [PMID: 29238184 PMCID: PMC5713692 DOI: 10.2147/copd.s145814] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Exacerbation history is used to grade the risk of COPD exacerbation, but its reliability and relationship to other risk factors and prior therapy is unclear. To examine these interrelationships, we conducted a post hoc analysis of patients in the TIOSPIR trial with ≥2 years' follow-up or who died on treatment. PATIENTS AND METHODS Patients were grouped by their annual exacerbation rate on treatment into nonexacerbators, infrequent, and frequent exacerbators (annual exacerbation rates 0, ≤1, and >1, respectively), and baseline characteristics discriminating among the groups were determined. We used univariate and multivariate analyses to explore the effect of baseline characteristics on risk of exacerbation, hospitalization (severe exacerbation), and death (all causes). RESULTS Of 13,591 patients, 6,559 (48.3%) were nonexacerbators, 4,568 (33.6%) were infrequent exacerbators, and 2,464 (18.1%) were frequent exacerbators; 45% of patients without exacerbations in the previous year exacerbated on treatment. Multivariate analysis identified baseline pulmonary maintenance medication as a predictive factor of increased exacerbation risk, with inhaled corticosteroid treatment associated with increased exacerbation risk irrespective of exacerbation history. CONCLUSION Our data confirm established risk factors for exacerbation, but highlight the limitations of exacerbation history when categorizing patients and the importance of prior treatment when identifying exacerbation risk.
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Affiliation(s)
- Peter MA Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Kay Tetzlaff
- Respiratory Medicine, Boehringer Ingelheim Pharma GmbH, Ingelheim am Rhein, Germany
| | - Daniel Dusser
- Department of Pneumology, Hôpital Cochin, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Achim Mueller
- Biostatistics and Data Sciences Europe, Boehringer Ingelheim Pharma GmbH, Biberach an der Riss, Germany
| | - Norbert Metzdorf
- Respiratory Medicine, Boehringer Ingelheim Pharma GmbH, Ingelheim am Rhein, Germany
| | - Antonio Anzueto
- Pulmonary Medicine and Critical Care, University of Texas Health Sciences Center and South Texas Veterans’ Health Care System, San Antonio, TX, USA
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11
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Ismaila AS, Birk R, Shah D, Zhang S, Brealey N, Risebrough NA, Tabberer M, Zhu CQ, Lipson DA. Once-Daily Triple Therapy in Patients with Advanced COPD: Healthcare Resource Utilization Data and Associated Costs from the FULFIL Trial. Adv Ther 2017; 34:2163-2172. [PMID: 28875459 PMCID: PMC5599456 DOI: 10.1007/s12325-017-0604-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Indexed: 11/27/2022]
Abstract
Introduction Chronic obstructive pulmonary disease is associated with a high healthcare resource and cost burden. Healthcare resource utilization was analyzed in patients with symptomatic chronic obstructive pulmonary disease at risk of exacerbations in the FULFIL study. Patients received either once-daily, single inhaler triple therapy (fluticasone furoate/umeclidinium/vilanterol) 100 µg/62.5 µg/25 µg or twice-daily dual inhaled corticosteroid/long-acting beta agonist therapy (budesonide/formoterol) 400 µg/12 µg. Methods FULFIL was a phase III, randomized, double-blind, double-dummy, multicenter study. Unscheduled contacts with healthcare providers were recorded by patients in a daily electronic diary; the costs of healthcare resource utilization were calculated post hoc using UK reference costs. Results Over 24 weeks, slightly fewer patients who received fluticasone furoate/umeclidinium/vilanterol (169/911; 18.6%) required contacts with healthcare providers compared with budesonide/formoterol (180/899; 20.0%). Over 52 weeks in an extension population, fewer patients who received fluticasone furoate/umeclidinium/vilanterol required unscheduled contacts with healthcare providers compared with budesonide/formoterol (25.2% vs. 32.7%). Non-drug costs per treated patient per year were lower in the fluticasone furoate/umeclidinium/vilanterol group than the budesonide/formoterol group over 24 and 52 weeks (£653.80 vs. £763.32 and £749.22 vs. £988.03, respectively), with the total annualized cost over 24 weeks being slightly greater for fluticasone furoate/umeclidinium/vilanterol than budesonide/formoterol (£1,289.35 vs. £1,267.45). Conclusions This healthcare resource utilization evidence suggests that, in a clinical trial setting over a 24- or 52-week timeframe, non-drug costs associated with management of a single inhaler fluticasone furoate/umeclidinium/vilanterol are lower compared with twice-daily budesonide/formoterol. Trial Registration ClinicalTrials.gov number: NCT02345161. Funding GSK Electronic supplementary material The online version of this article (doi:10.1007/s12325-017-0604-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Research Triangle Park, NC, USA.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Ruby Birk
- Respiratory Clinical Development, GSK, Stockley Park, Uxbridge, UK
| | - Dhvani Shah
- ICON Health Economics, ICON, New York, NY, USA
| | - Shiyuan Zhang
- Respiratory Research and Development, GSK, Collegeville, PA, USA
| | - Noushin Brealey
- Respiratory Clinical Development, GSK, Stockley Park, Uxbridge, UK
| | | | - Maggie Tabberer
- Value Evidence and Outcomes, GSK, Stockley Park, Uxbridge, UK
| | - Chang-Qing Zhu
- Respiratory Clinical Development, GSK, Stockley Park, Uxbridge, UK
| | - David A Lipson
- Respiratory Research and Development, GSK, King of Prussia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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12
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Martinez-Garcia MA, Miravitlles M. Bronchiectasis in COPD patients: more than a comorbidity? Int J Chron Obstruct Pulmon Dis 2017; 12:1401-1411. [PMID: 28546748 PMCID: PMC5436792 DOI: 10.2147/copd.s132961] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Computed tomography scan images have been used to identify different radiological COPD phenotypes based on the presence and severity of emphysema, bronchial wall thickening, and bronchiectasis. Bronchiectasis is defined as an abnormal dilation of the bronchi, usually as a result of chronic airway inflammation and/or infection. The prevalence of bronchiectasis in patients with COPD is high, especially in advanced stages. The identification of bronchiectasis in COPD has been defined as a different clinical COPD phenotype with greater symptomatic severity, more frequent chronic bronchial infection and exacerbations, and poor prognosis. A causal association has not yet been proven, but it is biologically plausible that COPD, and particularly the infective and exacerbator COPD phenotypes, could be the cause of bronchiectasis without any other known etiology, beyond any mere association or comorbidity. The study of the relationship between COPD and bronchiectasis could have important clinical implications, since both diseases have different and complementary therapeutic approaches. Longitudinal studies are needed to investigate the development of bronchiectasis in COPD, and clinical trials with treatments aimed at reducing bacterial loads should be conducted to investigate their impact on the reduction of exacerbations and improvements in the long-term evolution of the disease.
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Affiliation(s)
- Miguel Angel Martinez-Garcia
- Pneumology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Spain
| | - Marc Miravitlles
- CIBER de Enfermedades Respiratorias (CIBERES), Spain.,Pneumology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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13
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Nelsen LM, Vernon M, Ortega H, Cockle SM, Yancey SW, Brusselle G, Albers FC, Jones PW. Evaluation of the psychometric properties of the St George's Respiratory Questionnaire in patients with severe asthma. Respir Med 2017; 128:42-49. [PMID: 28610668 DOI: 10.1016/j.rmed.2017.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/18/2017] [Accepted: 04/27/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE Limited data exist on the quantitative validity of the St George's Respiratory Questionnaire (SGRQ) in asthma populations. This study evaluated the psychometric properties of the SGRQ in patients with severe asthma. METHODS This was a post-hoc analysis of pooled data from MENSA (N = 576; NCT01691508) and SIRIUS (N = 135; NCT01691521), two randomized, placebo controlled trials of mepolizumab in patients with severe asthma. Patients completed the SGRQ at Baseline and Exit (MENSA Week 32; SIRIUS Week 24). Distributional characteristics, internal consistency reliability, test-retest reliability, convergent and discriminant validity, known-groups validity and responsiveness were assessed. RESULTS Internal consistency reliability was acceptable for the total and domain scores at Baseline and Exit (Cronbach's α was 0.92 and 0.94 at Baseline and Exit, respectively, for the total score). Test-retest reliability was demonstrated (intraclass correlation coefficients >0.7) for total score and the Activity and Impacts domains. Convergent and discriminant validity were demonstrated with measures associated or not associated with respiratory-related health status. Known groups validity based on baseline FEV1% predicted, Asthma Control Questionnaire (ACQ)-5 score, exacerbations and eosinophil counts was demonstrated for the SGRQ total and domain scores. Responses to therapy based on clinician-rated response, patient-rated response, ACQ-5 change score and exacerbations generally correlated with improvements in SGRQ scores. CONCLUSIONS This analysis demonstrated that the SGRQ has acceptable psychometric properties in patients with severe asthma, exceeding the thresholds for adequate reliability, validity and responsiveness. The SGRQ appears to be a good instrument for identifying response to therapy in patients with severe asthma.
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Affiliation(s)
- Linda M Nelsen
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA.
| | | | - Hector Ortega
- Respiratory Therapeutic Area Unit, GSK, Research Triangle Park, NC, USA
| | - Sarah M Cockle
- Value Evidence and Outcomes, GSK, GSK House, Brentford, Middlesex, UK
| | - Steven W Yancey
- Respiratory Therapeutic Area Unit, GSK, Research Triangle Park, NC, USA
| | - Guy Brusselle
- Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Frank C Albers
- Respiratory Therapeutic Area Unit, GSK, Research Triangle Park, NC, USA
| | - Paul W Jones
- Value Evidence and Outcomes, GSK, GSK House, Brentford, Middlesex, UK
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14
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Simeone JC, Luthra R, Kaila S, Pan X, Bhagnani TD, Liu J, Wilcox TK. Initiation of triple therapy maintenance treatment among patients with COPD in the US. Int J Chron Obstruct Pulmon Dis 2016; 12:73-83. [PMID: 28053518 PMCID: PMC5191839 DOI: 10.2147/copd.s122013] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends triple therapy (long-acting muscarinic receptor antagonists, long-acting beta-2 agonists, and inhaled corticosteroids) for patients with only the most severe COPD. Data on the proportion of COPD patients on triple therapy and their characteristics are sparse and dated. Objective 1 of this study was to estimate the proportion of all, and all treated, COPD patients receiving triple therapy. Objective 2 was to characterize those on triple therapy and assess the concordance of triple therapy use with GOLD guidelines. PATIENTS AND METHODS This retrospective study used claims from the IMS PharMetrics Plus database from 2009 to 2013. Cohort 1 was selected to assess Objective 1 only; descriptive analyses were conducted in Cohort 2 to answer Objective 2. A validated claims-based algorithm and severity and frequency of exacerbations were used as proxies for COPD severity. RESULTS Of all 199,678 patients with COPD in Cohort 1, 7.5% received triple therapy after diagnosis, and 25.5% of all treated patients received triple therapy. In Cohort 2, 30,493 COPD patients (mean age =64.7 years) who initiated triple therapy were identified. Using the claims-based algorithm, 34.5% of Cohort 2 patients were classified as having mild disease (GOLD 1), 40.8% moderate (GOLD 2), 22.5% severe (GOLD 3), and 2.3% very severe (GOLD 4). Using exacerbation severity and frequency, 60.6% of patients were classified as GOLD 1/2 and 39.4% as GOLD 3/4. CONCLUSION In this large US claims database study, one-quarter of all treated COPD patients received triple therapy. Although triple therapy is recommended for the most severe COPD patients, spirometry is infrequently assessed, and a majority of the patients who receive triple therapy may have only mild/moderate disease. Any potential overprescribing of triple therapy may lead to unnecessary costs to the patient and health care system.
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Affiliation(s)
| | - Rakesh Luthra
- HEOR Value Demonstration Team, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Shuchita Kaila
- HEOR Value Demonstration Team, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | | | | | - Jieruo Liu
- Real-World Evidence, Evidera, Waltham, MA
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15
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Watz H, Tetzlaff K, Wouters EFM, Kirsten A, Magnussen H, Rodriguez-Roisin R, Vogelmeier C, Fabbri LM, Chanez P, Dahl R, Disse B, Finnigan H, Calverley PMA. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:390-8. [PMID: 27066739 DOI: 10.1016/s2213-2600(16)00100-4] [Citation(s) in RCA: 300] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/04/2016] [Accepted: 03/08/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Blood eosinophil counts might predict response to inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD) and a history of exacerbations. We used data from the WISDOM trial to assess whether patients with COPD with higher blood eosinophil counts would be more likely to have exacerbations if ICS treatment was withdrawn. METHODS WISDOM was a 12-month, randomised, parallel-group trial in which patients received 18 μg tiotropium, 100 μg salmeterol, and 1000 μg fluticasone propionate daily for 6 weeks and were then randomly assigned (1:1) electronically to receive either continued or reduced ICS over 12 weeks. We did a post-hoc analysis after complete ICS withdrawal (months 3-12) to compare rate of exacerbations and time to exacerbation outcomes on the basis of blood eosinophil subgroups of increasing cutoff levels. The WISDOM trial is registered at ClinicalTrials.gov, number NCT00975195. FINDINGS In the 2296 patients receiving treatment after ICS withdrawal, moderate or severe exacerbation rate was higher in the ICS-withdrawal group versus the ICS-continuation group in patients with eosinophil counts (out of total white blood cell count) of 2% or greater (rate ratio 1·22 [95% CI 1·02-1·48]), 4% or greater (1·63 [1·19-2·24]), and 5% or greater (1·82 [1·20-2·76]). The increase in exacerbation rate became more pronounced as the eosinophil cutoff level rose, with significant treatment-by-subgroup interaction reached for 4% and 5% only. Similar results were seen with eosinophil cutoffs of 300 cells per μL and 400 cells per μL, and mutually exclusive subgroups. INTERPRETATION Blood eosinophil counts at screening were related to the exacerbation rate after complete ICS withdrawal in patients with severe to very severe COPD and a history of exacerbations. Our data suggest that counts of 4% or greater or 300 cells per μL or more might identify a deleterious effect of ICS withdrawal, an effect not seen in most patients with eosinophil counts below these thresholds. FUNDING Boehringer Ingelheim.
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Affiliation(s)
- Henrik Watz
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany.
| | - Kay Tetzlaff
- Boehringer Ingelheim Pharma GmbH and Co KG, Ingelheim, Germany; Department of Sports Medicine, University of Tübingen, Tübingen, Germany
| | - Emiel F M Wouters
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Anne Kirsten
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | | | - Claus Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, German Center for Lung Research, Marburg, Germany
| | - Leonardo M Fabbri
- Department of Metabolic Medicine, University of Modena & Reggio Emilia, Modena, NOCSAE, AUSL Modena, Baggiovara, Italy
| | - Pascal Chanez
- Aix-Marseille Université, Department of Respiratory Diseases and CIC Nord, AP-HM-Hôpital Nord, Marseille, France
| | - Ronald Dahl
- University of Southern Denmark, Odense, Denmark
| | - Bernd Disse
- Boehringer Ingelheim Pharma GmbH and Co KG, Ingelheim, Germany
| | - Helen Finnigan
- Department of Biostatistics and Data Sciences, Boehringer Ingelheim, Bracknell, UK
| | - Peter M A Calverley
- Institute of Ageing and Chronic Disease, Aintree University Hospital, Liverpool, UK
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