Treatment with LABA versus LAMA for stable COPD: a systematic review and meta-analysis

Trends in initial pharmacological COPD treatment in primary care (2010-2021): a population-based study using the PHARMO Data Network

BACKGROUND

Pharmacological treatment is a cornerstone of chronic obstructive pulmonary disease (COPD) management, with general practitioners providing the most care. However, the lack of data on prescribing trends in initial pharmacotherapy in primary care hinders the understanding of how scientific and technical developments impact patient care and may also perpetuate suboptimal practices. Hence, this study aims to analyze trends in the initial pharmacological treatment of newly diagnosed COPD patients in Dutch primary care from 2010 to 2021.

METHODS

A repeated cross-sectional study was conducted via the PHARMO GP Database. Data were extracted from the electronic health records of individuals managed by general practitioners in the Netherlands within the PHARMO Data Network. Individuals aged ≥ 40 years at diagnosis with an International Classification of Primary Care code for COPD (R95) were included. Initial pharmacological treatment was identified based on the first prescription issued within 90 days postdiagnosis. The annual proportions of individuals receiving a specific treatment among those diagnosed were calculated and directly standardized by age and sex according to the 2021 Dutch population structure. Trend analysis was performed via joinpoint regression.

RESULTS

A total of 54,628 COPD patients were included (median [IQR] age: 65 [57-73]; 53.7% male), with 36.4% not receiving respiratory medication within 90 days of diagnosis, and 4.2% on other treatments. Trend analysis revealed that LAMA monotherapy increased from 13.4% in 2010 to 15.1% in 2015 and then declined to 11.0% by 2021. Moreover, LABA-ICS decreased from 17.6% to 8.5% between 2010 and 2018, after which it plateaued. In contrast, LABA-LAMA sharply increased, from 0.6% in 2010 to 9.6% in 2021. LABA monotherapy increased from 2.6% in 2010 to 5.7% in 2021. Triple therapy has remained constant. For reliever-only therapies, SABA increased from 8.5% in 2010 to 14.3% in 2018 and then stabilized, whereas SAMA and SABA-SAMA remained low throughout.

CONCLUSIONS

Shifts in initial pharmacological COPD treatment from 2010 to 2021 likely reflect the introduction of new inhalers and updated management strategies. However, a significant proportion of patients remain without GP prescriptions, which warrants further investigation.

Evaluation of comparative efficacy of Umeclidinium/Vilanterol versus other bronchodilators in the management of chronic obstructive pulmonary disease: a systematic review and meta-analysis of RCTs

BACKGROUND

UMEC/VI administered via a combination inhaler is associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild-to-moderate COPD. However, their efficacy compared to other bronchodilator mono or dual therapies still remains unclear.

OBJECTIVE

The objective of this research was to evaluate the therapeutic efficacy of UMEC/VI dual and UMEC/VI/FF triple therapies versus alternative bronchodilator regimens in COPD patients.

METHODS

A systematic search was conducted using four electronic databases (PubMed, EMBASE, Scopus, and Cochrane Library) to select publications published in peer-reviewed journals written in English. The odds ratio (OR) and risk ratio (RR) was calculated, along with their 95% confidence intervals. We assessed heterogeneity using Cochrane Q and I [2] statistics and the appropriate p-value. The analysis used RevMan 5.4.

RESULTS

The current meta-analysis includes 31,814 COPD patients from 17 RCTs. The meta-analysis results demonstrate that the combination of LABA and LAMA provides additive bronchodilation and improved lung function in COPD patients. We found that UMEC/VI dual therapy significantly improved FEV1 (OR 1.98 [95% CI 1.70-2.30]), TDI values (OR 1.97 [95% CI 1.72-2.26]), and reduced SGRQ total scores (OR 1.99 [95% CI 1.71-2.32]), with fewer drug-related adverse events (RR 0.58 [95% CI 0.53-0.64]). Similarly, UMEC/VI/FF triple therapy also showed similar benefits, with significant improvements in FEV1 (OR 1.93 [95% CI 1.73-2.15]), TDI values (OR 2.37 [95% CI 2.15-2.61]), and reduced SGRQ total scores (OR 1.83 [95% CI 1.63-2.05]), and fewer drug-related adverse events (RR 0.53 [95% CI 0.49-0.58]).

CONCLUSION

This systematic review and meta-analysis concludes that UMEC and VI combinations are an efficacious treatment option for symptomatic COPD patients.

The Bronchodilator and Anti-Inflammatory Effect of Long-Acting Muscarinic Antagonists in Asthma: An EAACI Position Paper

As cholinergic innervation is a major contributor to increased vagal tone and mucus secretion, inhaled long-acting muscarinic antagonists (LAMA) are a pillar for the treatment of chronic obstructive pulmonary disease and asthma. By blocking the muscarinic receptors expressed in the lung, LAMA improve lung function and reduce exacerbations in asthma patients who remained poorly controlled despite treatment with inhaled corticosteroids and long-acting β2 agonists. Asthma guidelines recommend LAMA as a third controller to be added on before the initiation of biologicals. In addition to bronchodilation, LAMA also exert anti-inflammatory and anti-fibrotic effects by inhibiting muscarinic receptors present in neutrophils, macrophages, fibroblasts and airway smooth muscle cells. Thus, besides bronchodilation, LAMA might provide additional therapeutic effects, thereby supporting an endotype-driven approach to asthma management. The Position Paper, developed by the Asthma Section of the European Academy of Allergy and Clinical Immunology, discusses the main cholinergic pathways in the lung, reviews the findings of significant clinical trials and real-life studies on LAMA use in asthma, examines the placement of these drugs in asthma clinical guidelines, and considers the potential for personalised medicine with LAMA in both adult and paediatric asthma patients.

Benefit of dual bronchodilator therapy on exacerbations in former and current smokers with chronic obstructive pulmonary disease in real-world clinical practice: a multicenter validation study (TOReTO)

BACKGROUND

Dual bronchodilator therapy, consisting of a long-acting beta-agonist (LABA) and a long-acting muscarinic antagonist (LAMA), has proven effective for patients with chronic obstructive pulmonary disease (COPD). However, it remains uncertain whether there are efficacy differences between current and former smokers with COPD. This study aims to explore the effectiveness of LABA/LAMA therapies in both these groups.

METHODS

The TOReTO trial assessed lung function, symptoms, health status, the occurrence of exacerbations, clinically significant exacerbations, and the use of LABA/LAMA therapies. These therapies include Tio/Olo, umeclidinium/vilanterol (Umec/Vi), and umeclidinium/vilanterol (Umec/Vi) are used in patients with COPD. The study examined the differences in outcomes between current and former smokers. To balance the baseline characteristics, propensity score matching (PSM) was employed.

RESULTS

Data from 967 patients were collected. After PSM, the time to the first acute exacerbation in current smokers was analyzed separately for the three treatment groups and was significantly different between them (p = 0.0457). Among, there are differences in the occurrence of acute exacerbation between treatment and smoking status in Umec/Vi (p = 0.0114). There is no significant difference in the treatment of former smokers among the three different groups of LABA/LAMA fixed-dose combinations (p = 0.3079). COPD-related symptoms remained stable throughout the treatment period. There were no significant differences in symptom scores, including CAT and mMRC, among the three groups at the end of the study.

CONCLUSIONS

The three fixed-dose combinations of LABA/LAMA showed no difference in reducing exacerbations in former smokers but did show differences in current smokers. This trend has clinical significance, and future research will be conducted to control influencing variables to validate this point. However, due to the non-randomized study design, these findings should be interpreted with caution.

[COPD inhaled therapy narrative review]

The basis of COPD maintenance treatment is the long-acting bronchodilators and the inhaled corticosteroids. Faced with the recent modifications in the clinical practice guidelines, we have carried out a review of studies that contrast the various therapeutic alternatives and pharmacological agents within each category, with the fundamental purpose of shedding light on which of these options prove to be more effective. Triple therapy stands out as essential in poorly controlled patients or with an eosinophilic phenotype, surpassing dual therapy. However, among the combinations of LAMA/LABA or LAMA/LABA/IC, no drug is observed to be superior in the reviewed evidence. Although triple therapies include corticosteroids, there does not appear to be a significant increase in side effects or pneumonia. Regarding monotherapy with LAMA, no significant differences are seen between the drugs, but in dual therapy with LABA/IC, the budesonide/formoterol combination seems to offer better control than fluticasone/salmeterol.

Long-acting B-2 agonists (LABA) or long-acting muscarinic antagonists (LAMA): which one may be the first option in group A COPD patients?

INTRODUCTION

Long-acting muscarinic antagonists (LAMA) or beta-2 agonists (LABA) have been recommended for symptom control in group A COPD patients as a first-line bronchodilator treatment in GOLD guidelines. However, there is no mention of priority/superiority between the two treatment options. We aimed to compare the effectiveness of these treatments in this group.

METHODS

The study cohort was formed of all subjects from six pulmonology clinics with an initial diagnosis of COPD who were new users of a LAMA or LABA from January 2020 to December 2021. Seventy-six group A COPD patients, in whom LABA or LAMA therapy had been started in the last 1 month as a first-line treatment, were included in our study. Participants were evaluated with spirometry, COPD Assessment Test (CAT), mMRC scale, and St. George Respiratory Questionnaire (SGRQ) for three times (baseline, 6-12th months).

RESULTS

There were 76 group A COPD patients with LAMA (67.1%) and LABA (32.9%). The number of patients who improved in CAT score at the end of the first year was significantly higher in patients using LAMA than those using LABA (p = 0.022); the improvement at minimum clinically important difference (MCID) in CAT score of LAMA group at 1st year was also significant (p = 0.044). SGRQ total and impact scores were found to be statistically lower at 1st year compared to baseline in patients using LAMA (p = 0.010 and 0.006, respectively). Significant improvement was detected in CAT and SGRQ scores at the 6th month visit in the LAMA group having emphysema (p = 0.032 and 0.002, respectively).

CONCLUSION

According to significant improvements in CAT and SGRQ score, LAMA may be preferred over LABA as a bronchodilator agent in group A COPD patients, especially in emphysema-dominant phenotype.

Treatment with systemic corticosteroid versus placebo for exacerbations of COPD: A systematic review and meta-analysis

BACKGROUND

For the treatment of COPD exacerbations, systemic corticosteroids are recommended in addition to short-acting bronchodilators. Although there have been several systemic reviews, many of the included studies were conducted before 2007 and a re-evaluation has not been performed since 2014. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety profile of systemic corticosteroids in patients with COPD during exacerbations.

METHODS

We searched relevant randomized control trials (RCTs) and analyzed the treatment failure, relapse, lung function, improvement in PaO2 and PaCO2, dyspnea, quality of life (QOL), length of stay in hospital and adverse events including hyperglycemia and mortality as the outcomes of interest.

RESULTS

We identified a total of 12 RCTs (N = 1336). Systemic corticosteroids significantly reduced the treatment failure (odds ratios; OR 0.41, 95% confidence intervals; CI 0.25 to 0.67) and hospital length of stay (mean difference; MD -1.57 days, 95% CI -2.36 to -0.78) and improved FEV1 (MD 0.18 L, 95% CI 0.08 to 0.28) and dyspnea (transitional dyspnea index; MD 1.90, 95% CI 0.26 to 3.54) in COPD exacerbations compared to placebo. However, systemic corticosteroids were associated with a significantly higher incidence of adverse events (OR 1.83, 95% CI 1.25 to 2.69) and hyperglycemia (OR 2.94, 95% CI 1.68 to 5.14).

CONCLUSIONS

In patients with moderate and severe COPD and severe obstructive impairment during exacerbations, systemic corticosteroids cause more adverse events, including hyperglycemia, than placebo but significantly reduce the treatment failure and hospital length of stay and improve FEV1 and dyspnea.

Advances in adrenergic receptors for the treatment of chronic obstructive pulmonary disease: 2023 update

INTRODUCTION

Strong scientific evidence and large experience support the use of β2-agonists for the symptomatic alleviation of COPD. Therefore, there is considerable effort in discovering highly potent and selective β2-agonists.

AREAS COVERED

Recent research on novel β2-agonists for the treatment of COPD. A detailed literature search was performed in two major databases (PubMed/MEDLINE and Scopus) up to September 2023."

EXPERT OPINION

Compounds that preferentially activate a Gs- or β-arrestin-mediated signaling pathway via β- adrenoceptors (ARs) are more innovative. Pepducins, which target the intracellular region of β2-AR to modulate receptor signaling output, have the most interesting profile from a pharmacological point of view. They stabilize the conformation of the β2-AR and influence its signaling by interacting with the intracellular receptor-G protein interface. New bifunctional drugs called muscarinic antagonist-β2 agonist (MABA), which have both muscarinic receptor (mAChR) antagonism and β2-agonist activity in the same molecule, are a new opportunity. However, all tested compounds have been shown to act predominantly as mAChR antagonists or β2-agonists. An intriguing idea is to utilize allosteric modulators that bind to β2-ARs at sites different than those bound by orthosteric ligands to augment or reduce the signaling transduced by the orthosteric ligand.

DT-0111: a novel P2X3 receptor antagonist

Extracellular adenosine 5'-triphosphate (ATP) acts as an autocrine and paracrine agent, the actions of which on affected cells are mediated by P2 receptors (P2R), which include trans cell-membrane cationic channels (P2XRs), and G protein coupled receptors (P2YRs). The mammalian P2X receptors form homotrimeric or heterotrimeric cationic channels, each of which contains three ATP-binding sites. There are seven homotrimeric P2X receptors (P2X1-7) and three heteromeric (P2X2/P2X3, P2X4/P2X6, P2X1/P2X5). In the lungs and airways, ATP activates P2X3 and P2X2/3 receptors (P2X3R, P2X2/3R, respectively) localized on vagal sensory nerve terminals resulting in bronchoconstriction, and cough, and probably also localized release of pro-inflammatory neuropeptides via the axon reflex. Currently, several P2X3R and P2X2/3R antagonists are being developed as drug-candidates for the treatment of chronic cough. This report presents the receptor affinity data of a novel water-soluble small molecule, DT-0111, that acts as a selective P2X3R antagonist.

Classification of chronic obstructive pulmonary disease as ABCD according to the GOLD 2011 and 2017 versions in patients at the University Medical Center in Ho Chi Minh City, Vietnam

In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) substantially changed its ABCD group categorization. Although several studies had been conducted to assess the impact of the new GOLD category, there was no research on the change in the GOLD classification in Vietnam. This retrospective analysis was conducted at the Asthma and Chronic Obstructive Pulmonary Disease (COPD) Clinic at the University Medical Center in Ho Chi Minh City, Vietnam. Our study population comprised patients visiting the medical center from January 2018 to January 2020. We categorized patients' demographics, clinical characteristics, and pharmacotherapy based on GOLD 2011 and 2017 guidelines. A comparison between the two versions was also determined. A total of 457 patients were included in this study. The percentage of groups A, B, C, and D according to GOLD 2011 was 5%, 20.8%, 13.1%, and 61.1%, respectively, and according to GOLD 2017, it was 6.1%, 34.1%, 12%, and 47.8%, respectively. In terms of gender, male patients constituted nearly 95% of the study's population (433/457 patients). Regarding pharmacotherapy, approximately 20% of the low-risk group (groups A and B) was overtreated with inhaled corticosteroid (ICS) components: long-acting β-agonists (LABA) + ICS (15.8%) and long-acting muscarinic antagonist + LABA + ICS (3.8%). There were 13.3% and 1.1% of patients transferred from D to B and from C to A, respectively. All of them had a lower predicted percentage of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and FEV1/FVC than the patients who remained in groups B or A (p<0.005). This is the first research in Vietnam to show the distribution of COPD patients using both the GOLD 2011 and GOLD 2017 criteria. 14% of patients were reclassified from high-risk to low-risk groups when changing from the 2011 version to the 2017 one, and there was discordance of medications between guidelines and real-life practice. Therefore, clinicians should use their clinical competence to consider patients' conditions before deciding on the appropriate therapeutic approach. Consequently, further studies were required to evaluate the effect of the change in the GOLD classification.

Inhaled Corticosteroids and the Risk of Nontuberculous Mycobacterial Pulmonary Disease in Chronic Obstructive Pulmonary Disease: Findings from a Nationwide Population-Based Study

Studies have shown increased nontuberculous mycobacterial pulmonary disease (NTM) incidence with inhaled corticosteroid (ICS) use in patients with chronic respiratory diseases; however, this association in chronic obstructive pulmonary disease (COPD) remains insufficiently studied. Using a nationwide population-based database of the Korean National Health Insurance Service, newly diagnosed COPD patients (2005-2018) treated with inhaled bronchodilators were selected. An NTM case was defined by the presence of the first diagnostic code following inhaled bronchodilator use. Results indicated that ICS users did not have an increased risk of NTM disease compared to non-ICS users (hazard ratio (HR), 1.121; 95% confidence interval (CI), 0.950-1.323; p = 0.176). However, in a subgroup analysis, the highest quartile of the cumulative ICS dose was associated with the development of NTM (1.200, 0.950-1.323, p = 0.050). Medium (1.229, 1.008-1.499, p = 0.041) and high daily doses of ICS (1.637, 1.241-2.160, p < 0.001) were associated with an increased risk of NTM disease. There was no difference in the risk of NTM according to ICS type. ICS use may increase the risk of developing NTM disease in patients with COPD. Physicians should weigh the potential benefits and risks of ICS, especially when using high doses and prolonged durations.

Exploring the appropriateness of prescribing practice of inhaled pharmacotherapy among Aboriginal Australians in the Top End Northern Territory of Australia: a retrospective cohort study

BACKGROUND

Aboriginal Australians are reported to have a high burden of chronic airway diseases. However, prescribing patterns and related outcomes of airway directed inhaled pharmacotherapy, (short-acting beta agonists (SABA), short-acting muscarinic antagonists (SAMA), long-acting β-agonists (LABA), long-acting muscarinic antagonists (LAMA) and inhaled corticosteroids (ICS)) among Aboriginal Australian patients with chronic airway disease have been sparsely reported in the past.

METHODS

A retrospective cohort study was conducted, using clinical, spirometry data, chest radiology, primary healthcare (PHC) presentations and hospital admission rates among Aboriginal patients identified to have been prescribed inhaled pharmacotherapy in remote and rural communities referred to the respiratory specialist service in the Top End, Northern Territory of Australia.

RESULTS

Of the 372 identified active patients, 346 (93%) had inhaled pharmacotherapy prescribed (64% female, median age 57.7 years). ICS was the most common prescription (72% of the total cohort) and was recorded to be prescribed in 76% of patients with bronchiectasis, and 80% of patients with asthma or chronic obstructive pulmonary disease (COPD). Fifty-eight percent of patients had a respiratory hospital admission and 57% had a recorded PHC presentation for a respiratory issue during the study period, with a higher rate of hospital admissions among patients prescribed ICS compared with those on SAMA/SABA or LAMA/LABA without ICS (median rate (per person per year) 0.42 vs 0.21 and 0.21 (p=0.004). Regression models demonstrated that presence of COPD or bronchiectasis alongside ICS was associated with significantly increased hospitalisation rates (1.01 admissions/person/year (95% CI 0.15 to 1.87) and 0.71 admissions/person/year (95% CI 0.23 to 1.18) against patients without COPD/bronchiectasis, respectively).

CONCLUSIONS

This study demonstrates that among Aboriginal patients with chronic airway diseases, ICS is the most common inhaled pharmacotherapy prescribed. Although LAMA/LABA and concurrent ICS use may be appropriate among patients with asthma and COPD, the use of ICS may have detrimental effects among those with underlying bronchiectasis either in isolation or concurrent COPD and bronchiectasis, potentially leading to higher hospital admission rates.

A Prediction Scoring Model for the Effect of Withdrawal or Addition of Inhaled Corticosteroids in Patients with Chronic Obstructive Pulmonary Disease

Purpose

The aims of this study were to develop a scoring model that predicts the effects of withdrawing inhaled corticosteroids (ICSs) from triple therapy and to examine its adaptability when applied to assess the effect of adding ICSs to dual bronchodilators patients with chronic obstructive pulmonary disease (COPD).

Patients and Methods

A scoring model was developed using the IMPACT study dataset, consisting of 2389 COPD patients treated with triple therapy before enrollment (ICS withdrawal dataset). The developed model consisted of COPD duration, Acute exacerbation history, Sex, Pulmonary function tests, blood Eosinophil count, and Race (CASPER) and was used to predict composite events of moderate-to-severe exacerbation, all-cause mortality, and pneumonia. Treatment heterogeneity was assessed using Cox interaction analyses. The CASPER model was applied to 540 COPD patients treated with dual bronchodilator before enrollment (ICS addition dataset). Validity was assessed using Harrell's C-index, time-dependent receiver operating characteristic curves, and calibration plots.

Results

The cumulative incidence of the composite event was 60.1% over 12 months in the ICS withdrawal dataset. Cox interaction analyses revealed that ICS was different according to race and blood eosinophil counts. The hazard ratios (HRs) for dual bronchodilator compared with triple therapy were 1.318 (95% confidence interval (CI)=1.170-1.485; P-value <0.001) in whites and 0.922 (95% CI = 0.712-1.195; P-value=0.541) in other races. The treatment effect was different in the eosinophil count ≥0.3 group (HR = 1.586; 95% CI = 1.274-1.975) and in the eosinophil count = 0.1-0.3 group (HR = 1.211; 95% CI = 1.041-1.408), but it was same in the eosinophil count <0.1 (HR = 1.009; P-value=0.940). The CASPER model performed well with good discrimination and calibration, which were superior to the prediction based on exacerbation history and blood eosinophil count.

Conclusion

The presented CASPER model might be able to predict and compare the risk of composite events when dual bronchodilator or triple therapy is administered to COPD patients.

Evidence-based management approaches for patients with severe chronic obstructive pulmonary disease (COPD): A practice review

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) face limited treatment options and inadequate access to palliative care.

AIM

To provide a pragmatic overview of clinical guidelines and produce evidence-based recommendations for severe COPD. Interventions for which there is inconsistent evidence to support their use and areas requiring further research were identified.

DESIGN

Practice review of guidelines supported by scoping review methodology to examine the evidence reporting the use of guideline-recommended interventions.

DATA SOURCES

An electronic search was undertaken in MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Database of Systematic Reviews, complemented by web searching for guidelines and publications providing primary evidence (July 2021). Guidelines published within the last 5 years and evidence in the last 10 years were included.

RESULTS

Severe COPD should be managed using a multidisciplinary approach with a holistic assessment. For stable patients, long-acting beta-agonist/long-acting muscarinic antagonist and pulmonary rehabilitation are recommended. Low dose opioids, self-management, handheld fan and nutritional support may provide small benefits, whereas routine corticosteroids should be avoided. For COPD exacerbations, systematic corticosteroids, non-invasive ventilation and exacerbation action plans are recommended. Short-acting inhaled beta-agonists and antibiotics may be considered but pulmonary rehabilitation should be avoided during hospitalisation. Long term oxygen therapy is only recommended for patients with chronic severe hypoxaemia. Short-acting anticholinergic inhalers, nebulised opioids, oral theophylline or telehealth are not recommended.

CONCLUSIONS

Recommended interventions by guidelines are not always supported by high-quality evidence. Further research is required on efficacy and safety of inhaled corticosteroids, antidepressants, benzodiazepines, mucolytics, relaxation and breathing exercises.

Escalation Time to Open Triple Combination Therapy from the Initiation of LAMA versus ICS/LABA in COPD Management: Findings from Comparing the Incidence of Tiotropium and ICS/LABA in Real-World Use in South Korea (CITRUS) Study

Background: bronchodilators are the key treatment for chronic obstructive pulmonary disease (COPD), however, inhaled corticosteroids (ICSs)/long-acting β2-agonists (LABA) are widely prescribed. We compared the escalation time to open triple combination therapy between long-acting muscarinic receptor antagonists (LAMA) and ICS/LABA in COPD management. Methods: this retrospective study included COPD patients selected from the National Health Insurance Service of South Korea from January 2005 to April 2015. The primary outcome was the escalation time to triple therapy in patients who initially received LAMA or ICS/LABA. Other outcomes included risk factors predisposing escalation to triple combination therapy. Results: a total of 2444 patients were assigned to the LAMA or ICS/LABA groups. The incidences of triple combination therapy in the LAMA and ICS/LABA groups were 81.0 and 139.8 per 1000 person-years, respectively (p < 0.001); the median times to triple therapy escalation were 281 and 207 days, respectively (p = 0.03). Treatment with ICS/LABA showed a higher risk of triple therapy escalation compared to LAMA (hazard ratio (HR), 1.601; 95% confidence interval (CI), 1.402–1.829). The associated risk factor was male sex. (HR, 1.564; 95% CI, 1.352–1.809). Conclusions: the initiation of COPD treatment with LAMA is associated with a reduced escalation time to triple therapy compared with ICS/LABA.

Efficacy of Aclidinium Bromide According to Baseline Therapy: Post-Hoc Analysis of ASCENT-COPD Randomized Trial

INTRODUCTION

Long-acting muscarinic antagonists (LAMAs), long-acting β₂-agonists (LABAs), inhaled corticosteroids (ICS), and their combinations, are recommended for the treatment of chronic obstructive pulmonary disease (COPD). This study aimed to determine whether the safety and efficacy of aclidinium bromide differs by baseline maintenance LABA and ICS therapies.

METHODS

ASCENT-COPD was a phase 4, multicenter, double-blind, randomized, placebo-controlled, parallel-group study of patients with moderate-to-very severe COPD and increased cardiovascular risk. Patients were randomized 1:1 to receive aclidinium 400 μg or placebo twice daily, via a multidose dry-powder inhaler for up to 3 years. Outcomes included time to first major adverse cardiovascular events (MACE), all-cause mortality, change from baseline in trough forced expiratory volume in 1 s (FEV₁), and COPD assessment test (CAT) total score over 3 years, and annual moderate-to-severe COPD exacerbation rate in patients receiving aclidinium or placebo with maintenance LABA monotherapy, ICS monotherapy, LABA + ICS (fixed/free), or no maintenance therapy (neither LABA nor ICS) at baseline.

RESULTS

A total of 3589 patients were included (LABA, n = 227; ICS, n = 290; LABA + ICS, n = 2058; no maintenance, n = 1130). Aclidinium did not increase the risk of MACE or all-cause mortality versus placebo, regardless of baseline maintenance treatment. Reductions in moderate-to-severe exacerbation rates were observed with aclidinium versus placebo in all subgroups [LABA 43% (P = 0.046); ICS 25% (P = 0.202); LABA + ICS 22% (P = 0.003); no maintenance 18% (P = 0.130)]. Aclidinium improved morning trough FEV₁ irrespective of baseline therapy and CAT total scores, except for LABA and ICS subgroups, versus placebo at several time points.

CONCLUSION

In patients with moderate-to-severe COPD and CV risk factors, the addition of aclidinium to maintenance therapy with LABA or LABA + ICS provided further benefit.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01966107.

The Effects of Inhaled Airway Directed Pharmacotherapy on Decline in Lung Function Parameters Among Indigenous Australian Adults With and Without Underlying Airway Disease

BACKGROUND

The trajectory of lung function decline among Indigenous patients with or without underlying chronic airway disease (COPD and concomitant bronchiectasis) and with use of inhaled pharmacotherapy, including inhaled corticosteroids (ICS), has not been reported in the past.

METHODS

Adult Indigenous Australian patients identified to have undergone at least two or more lung function tests (LFTs) between 2012 and 2020 were assessed for changes in the lung function parameters (LFPs) between the first and last recorded LFTs.

RESULTS

Of the total 1350 patients identified to have undergone LFTs, 965 were assessed to fulfil session quality, 115 (n=58 females) were eligible to be included with two or more LFTs. Among the 115 patients, 49% showed radiological evidence of airway diseases, and 77% were on airway directed inhaled pharmacotherapy. Median time between LFTs was 1.5 years (IQR 0.86,5.85), with no significant differences in LFPs noted between first and last LFT. Overall rate of change (mL/year) showed considerable variation for FVC (median -37.55 mL/year [IQR -159.88,92.67]) and FEV1 (-18.74 mL/year [-102.49,71.44]) with minimal change in FEV1/FVC (0.00 ratio/year [-0.03,0.01]). When stratified by inhaled pharmacotherapy group, however, patients using ICS showed significantly greater rate of FEV1 decline (-48.64 mL/year [-110.18,62.5]) compared to those using pharmacotherapy with no ICS (15.46 mL/year [-73.5,74.62]) and those using no pharmacotherapy (-5.76 mL/year [-63.19,67.34]) (p=0.022). Additionally, a greater proportion of these patients reached the threshold for excessive FEV1 decline (64%) compared to those using pharmacotherapy without ICS (44%) and those using no pharmacotherapy (52%).

CONCLUSION

Decline in LFPs occurs commonly among adult Indigenous population, especially, excessive so among those using inhaled pharmacotherapy containing ICS.

[COPD inhaled therapy narrative review]

Inhaled therapy with long-acting bronchodilators is the base of pharmacological treatment in COPD. In order to find out those that offer better control, a search was carried out in Medline (Pubmed). Comparative studies of inhaler therapy in COPD patients were analyzed. The comparison between the fixed combination LABA/LAMA versus LABA/CI in non-exacerbating patients, revealed a better control with LABA/LAMA. Within the LABA/CI combinations, budesonide/formoterol combination offered better control. LAMA inhalers revealed no great differences, but when compared to LABA, it offered a better control. Regarding triple therapy in a single device, was superior to double therapy and to triple therapy in two devices, with no relevant differences among the available combinations.

Triple versus LAMA/LABA combination therapy for patients with COPD: a systematic review and meta-analysis

Background

Recently, the addition of inhaled corticosteroid (ICS) to long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist (LABA) combination therapy has been recommended for patients with COPD who have severe symptoms and a history of exacerbations because it reduces the exacerbations. In addition, a reducing effect on mortality has been shown by this treatment. However, the evidence is mainly based on one large randomized controlled trial IMPACT study, and it remains unclear whether the ICS add-on treatment is beneficial or not. Recently, a large new ETHOS trial has been performed to clarify the ICS add-on effects. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety including ETHOS trial.

Methods

We searched relevant randomized control trials (RCTs) and analyzed the exacerbations, quality of life (QOL), dyspnea symptom, lung function and adverse events including pneumonia and mortality, as the outcomes of interest.

Results

We identified a total of 6 RCTs in ICS add-on protocol (N = 13,579). ICS/LAMA/LABA treatment (triple therapy) significantly decreased the incidence of exacerbations (rate ratio 0.73, 95% CI 0.64–0.83) and improved the QOL score and trough FEV₁ compared to LAMA/LABA. In addition, triple therapy significantly improved the dyspnea score (mean difference 0.33, 95% CI 0.18–0.48) and mortality (odds ratio 0.66, 95% CI 0.50–0.87). However, triple therapy showed a significantly higher incidence of pneumonia (odds ratio 1.52, 95% CI 1.16–2.00). In the ICS-withdrawal protocol including 2 RCTs, triple therapy also showed a significantly better QOL score and higher trough FEV₁ than LAMA/LABA. Concerning the trough FEV₁, QOL score and dyspnea score in both protocols, the differences were less than the minimal clinically important difference.

Conclusion

Triple therapy causes a higher incidence of pneumonia but is a more preferable treatment than LAMA/LABA due to the lower incidence of exacerbations, higher trough FEV₁ and better QOL score. In addition, triple therapy is also superior to LABA/LAMA due to the lower mortality and better dyspnea score. However, these results should be only applied to patients with symptomatic moderate to severe COPD and a history of exacerbations.

Clinical Trial Registration: PROSPERO; CRD42020191978.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01777-x.

Triple versus LAMA/LABA combination therapy for Japanese patients with COPD: A systematic review and meta-analysis

BACKGROUND

In symptomatic COPD patients with a history of exacerbations, additional treatment with inhaled corticosteroid (ICS) to long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist (LABA) combination therapy is recommended based on the evidence of low incidence of exacerbations but with a caution for pneumonia. However, ethnic differences may affect the response to drugs. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of this treatment in the Japanese population (PROSPERO: CRD42020191978).

METHODS

We searched relevant randomized control trials and analyzed the exacerbations, quality of life, lung function, and adverse events including pneumonia and mortality as the outcomes of interest.

RESULTS

We identified a total of three RCTs (N = 632). Treatment with ICS/LAMA/LABA triple therapy significantly decreased the exacerbations (rate ratio, 0.56; 95% CI, 0.38 to 0.85) and improved the trough FEV₁ (mean difference, 0.04; 95% CI, 0.01 to 0.07) compared to LAMA/LABA therapy. However, triple therapy showed a significantly higher incidence of pneumonia compared to LAMA/LABA (odds ratio, 3.38; 95% CI, 1.58 to 7.22). Concerning other adverse events including mortality, there were no significant difference between these therapies.

CONCLUSIONS

In the current meta-analysis of the Japanese population, we confirmed that triple therapy causes a higher incidence of pneumonia than LAMA/LABA treatment but is a more preferable treatment since it showed a lower incidence of exacerbations and higher trough FEV₁ in patients with symptomatic moderate to severe COPD. However, since the sample sizes were not statistically large enough, further trials involving Japanese patients are needed.

ACO (Asthma-COPD Overlap) Is Independent from COPD, a Case in Favor: A Systematic Review

Asthma and chronic obstructive pulmonary disease (COPD) are now recognized to be able to co-exist as asthma-COPD overlap (ACO). It is clinically relevant to evaluate whether patients with COPD concurrently have components of asthma in primary care. This is because: (i) ACO is a relatively common condition among asthma (over 40 years of age) or COPD irrespective of its diagnosis criteria; (ii) patients with ACO can have higher frequency of exacerbation and more rapid decline in lung function than those with asthma or COPD; and (iii) asthmatic features such as eosinophilic airway inflammation are promising indicators for prediction of inhaled corticosteroid-responsiveness in COPD. The aim of this review to evaluate diagnostic markers for ACO. We searched PubMed for articles related to ACO published until 2020. Articles associated with diagnostic biomarkers were included. We identified a total of 25 studies, some of which have revealed that a combination of biomarkers such as fractional exhaled nitric oxide and serum immunoglobulin E is useful to discern type 2 inflammation in the airways of COPD. Here, we review the current understanding of the clinical characteristics, biomarkers and molecular pathophysiology of ACO in the context of how ACO can be differentiated from COPD.

The Impact of Muscarinic Receptor Antagonists on Airway Inflammation: A Systematic Review

Long-acting muscarinic receptor antagonists (LAMAs) are the cornerstone for the treatment of chronic obstructive pulmonary disease (COPD); furthermore, tiotropium is approved as add-on therapy in severe asthmatic patients. Accumulating evidence suggests that LAMAs may modulate airway contractility and airway hyperresponsiveness not only by blocking muscarinic acetylcholine receptors (mAchRs) expressed on airway smooth muscle but also via anti-inflammatory mechanisms by blocking mAchRs expressed on inflammatory cells, submucosal glands, and epithelial cells. The aim of this systematic review, performed according to the PRISMA-P guidelines, was to provide a synthesis of the literature on the anti-inflammatory impact of muscarinic receptor antagonists in the airways. Most of the current evidence originates from studies on tiotropium, that demonstrated a reduction in synthesis and release of cytokines and chemokines, as well as the number of total and differential inflammatory cells, induced by different pro-inflammatory stimuli. Conversely, few data are currently available for aclidinium and glycopyrronium, whereas no studies on the potential anti-inflammatory effect of umeclidinium have been reported. Overall, a large body of evidence supports the beneficial impact of tiotropium against airway inflammation. Further well-designed randomized controlled trials are needed to better elucidate the anti-inflammatory mechanisms leading to the protective effect of LAMAs against exacerbations via identifying suitable biomarkers.

Extracellular adenosine 5'-triphosphate in pulmonary disorders

Adenosine 5'-triphosphate (ATP) is found in every cell of the human body where it plays a critical role in cellular energetics and metabolism. ATP is released from cells under physiologic and pathophysiologic condition; extracellular ATP is rapidly degraded to adenosine 5'-diphosphate (ADP) and adenosine by ecto-enzymes (mainly, CD39 and CD73). Before its degradation, ATP acts as an autocrine and paracrine agent exerting its effects on targeted cells by activating cell surface receptors named P2 Purinergic receptors. The latter are expressed by different cell types in the lungs, the activation of which is involved in multiple pulmonary disorders. This succinct review summarizes the role of ATP in inflammation processes associated with these disorders including bronchoconstriction, cough, mechanical ventilation-induced lung injury and idiopathic pulmonary fibrosis. All of these disorders still constitute unmet clinical needs. Therefore, the various ATP-signaling pathways in pulmonary inflammation constitute attractive targets for novel drug-candidates that would improve the management of patients with multiple pulmonary diseases.