1
|
Cazzola M, Rogliani P, Ora J, Calzetta L, Matera MG. Cardiovascular diseases or type 2 diabetes mellitus and chronic airway diseases: mutual pharmacological interferences. Ther Adv Chronic Dis 2023; 14:20406223231171556. [PMID: 37284143 PMCID: PMC10240559 DOI: 10.1177/20406223231171556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/06/2023] [Indexed: 06/08/2023] Open
Abstract
Chronic airway diseases (CAD), mainly asthma and chronic obstructive pulmonary disease (COPD), are frequently associated with different comorbidities. Among them, cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) pose problems for the simultaneous treatment of CAD and comorbidity. Indeed, there is evidence that some drugs used to treat CAD negatively affect comorbidity, and, conversely, some drugs used to treat comorbidity may aggravate CAD. However, there is also growing evidence of some beneficial effects of CAD drugs on comorbidities and, conversely, of the ability of some of those used to treat comorbidity to reduce the severity of lung disease. In this narrative review, we first describe the potential cardiovascular risks and benefits for patients using drugs to treat CAD and the potential lung risks and benefits for patients using drugs to treat CVD. Then, we illustrate the possible negative and positive effects on T2DM of drugs used to treat CAD and the potential negative and positive impact on CAD of drugs used to treat T2DM. The frequency with which CAD and CVD or T2DM are associated requires not only considering the effect that drugs used for one disease condition may have on the other but also providing an opportunity to develop therapies that simultaneously favorably impact both diseases.
Collapse
Affiliation(s)
- Mario Cazzola
- Chair of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Paola Rogliani
- Chair of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
- Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Chair of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| |
Collapse
|
2
|
Zhang C, Zhang M, Wang Y, Xiong H, Huang Q, Shuai T, Liu J. Efficacy and cardiovascular safety of LAMA in patients with COPD: a systematic review and meta-analysis. J Investig Med 2021; 69:1391-1398. [PMID: 34362778 PMCID: PMC8639957 DOI: 10.1136/jim-2021-001931] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is at present the third leading cause of death in the world. Long-acting muscarinic antagonist (LAMA) is widely used as a bronchodilator in patients with COPD. However, there is controversy concerning their cardiovascular safety. This meta-analysis aims to assess the efficacy and cardiovascular safety of LAMAs versus placebo in patients with COPD. We searched Pub Med, Embase, Cochrane Library, and Web of Science to identify studies that compared LAMA with placebo in patients with COPD. Twenty-one studies involving 24,987 participants were finally included in the analysis. There was no significant difference in the incidence of all adverse events (risk ratio (RR)=1.01, 95% CI 1.00 to 1.02, I2=15.2%) and cardiovascular events (RR=0.98, 95% CI 0.88 to 1.09, I2=4.9%) in patients treated with LAMAs versus placebo. LAMAs significantly improved trough forced expiratory volume in 1 s (weighted mean difference (WMD)=0.12, 95% CI 0.10 to 0.14, I2=86.6%), Transitional Dyspnea Index (WMD=0.75, 95% CI 0.56 to 0.94, I2=0%), and St. George's Respiratory Questionnaire (WMD=‒2.50, 95% CI ‒3.32 to ‒1.69, I2=39.8%). Moreover, LAMAs significantly reduced the incidence of exacerbation in patients with COPD (RR=0.85, 95% CI 0.79 to 0.91, I2=69.9%). LAMAs are safe therapy and play a pivotal role in improving lung function, dyspnea, and health status, and reducing the exacerbation in patients with COPD.
Collapse
Affiliation(s)
- Chuchu Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Meng Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Yalei Wang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Huaiyu Xiong
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Qiangru Huang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Tiankui Shuai
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Liu
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
| |
Collapse
|
3
|
Chapman KR, Wise RA, Scirica BM, Bhatt DL, Daoud SZ, Lythgoe D, Gil EG. Long-acting antimuscarinic therapy in patients with chronic obstructive pulmonary disease receiving beta-blockers. Respir Res 2021; 22:272. [PMID: 34686204 PMCID: PMC8532273 DOI: 10.1186/s12931-021-01861-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Abstract
Background Beta-blocker therapies for cardiovascular comorbidities are often withheld in patients with chronic obstructive pulmonary disease (COPD) due to potential adverse effects on airway obstruction. We carried out a post hoc analysis to determine the efficacy and safety of aclidinium in patients with moderate-to-very severe COPD and increased cardiovascular risk receiving beta-blockers at baseline versus non-users. Methods ASCENT-COPD was a Phase 4, multicenter, double-blind, randomized, placebo-controlled, parallel-group study. Patients were randomized 1:1 to aclidinium or placebo twice-daily for up to 3 years. Outcomes included risk of (time to first) major adverse cardiovascular events (MACE), all-cause mortality, and lung function over 3 years, and exacerbations over 1 year. Results Of 3589 patients, 1269 (35.4%) used beta-blockers and 2320 (64.6%) were non-users at baseline. Aclidinium did not statistically increase the risk of MACE (beta-blocker user: hazard ratio 1.01 [95% CI 0.62–1.64]; non-user: 0.80 [0.51–1.24]; interaction P = 0.48) or all-cause mortality (beta-blocker user: 1.13 [0.78–1.64]; non-user: 0.89 [0.62–1.26]; interaction P = 0.35), in patients using beta-blockers. Aclidinium reduced annualized rate of moderate-to-severe COPD exacerbation (beta-blocker user: rate ratio 0.75 [95% CI 0.60–0.94, P = 0.013]; non-user: 0.79 [0.67–0.93, P = 0.005]), delayed time to first exacerbation, and improved lung function versus placebo. There was greater trough FEV1 benefit in beta-blocker users versus non-users (least squares mean difference at 52 weeks: 111 mL [95% CI 74 mL–147 mL] versus 69 mL [42 mL–97 mL]; interaction P = 0.041). Conclusions This post hoc analysis supports long-acting anti-muscarinic use with concomitant beta-blockers in patients with moderate-to-very severe COPD and cardiovascular comorbidity. Trial registration: ClinicalTrials.gov, NCT01966107, Registered 16 October 2013, https://clinicaltrials.gov/ct2/show/NCT01966107.
Collapse
Affiliation(s)
- Kenneth R Chapman
- Asthma and Airway Centre, University of Toronto, Toronto, ON, Canada. .,Asthma and Airway Centre, University Health Network, 7th Floor East Wing, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
| | - Robert A Wise
- Pulmonary Function Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin M Scirica
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sami Z Daoud
- Late-Stage Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | | | | |
Collapse
|
4
|
D'Urzo AD, Singh D, Donohue JF, Chapman KR, Wise RA. Aclidinium bromide/formoterol fumarate as a treatment for COPD: an update. Expert Rev Respir Med 2021; 15:1093-1106. [PMID: 34137664 DOI: 10.1080/17476348.2021.1920403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Aclidinium/formoterol is a long-acting muscarinic antagonist (LAMA) and long-acting β2-agonist (LABA) dual bronchodilator used as a maintenance treatment for patients with chronic obstructive pulmonary disease (COPD). The efficacy of aclidinium/formoterol has been demonstrated consistently in patients with moderate-to-severe COPD versus placebo and monocomponents, with a comparable safety profile.Areas covered: This review examines recent research findings that expand our understanding of the impact of aclidinium/formoterol on the burden of COPD. Reviewed outcomes include improvements in lung function, respiratory symptoms, health-related quality of life, exercise tolerance, exacerbation rates, and clinically important deteriorations. In addition, the reported cardiovascular safety of aclidinium and current LAMA/LABA treatment recommendations are discussed.Expert opinion: Aclidinium/formoterol reduces disease burden in patients with COPD, including those that are treatment-naïve, without a significant increase in safety risk compared with monotherapies. Furthermore, evidence supports an improvement in lung function over a 24-hour period with aclidinium/formoterol treatment versus monotherapy and placebo, which may offer an advantage over some once-daily LAMA/LABA combinations. In summary, the recent evidence discussed in this review adds weight to the use of LAMA/LABA combinations as an initial therapy for certain patients newly diagnosed with COPD.
Collapse
Affiliation(s)
- Anthony D D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundations Trust, University of Manchester, Manchester, UK
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Pulmonary Critical Medicine, Chapel Hill, NC, USA
| | - Kenneth R Chapman
- Asthma and Airway Center, University Health Network, Toronto, ON, Canada
| | - Robert A Wise
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
5
|
Kaplan A, Chang KL. Tiotropium in asthma - perspectives for the primary care physician. Postgrad Med 2020; 133:552-564. [PMID: 32896185 DOI: 10.1080/00325481.2020.1816329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Asthma is a heterogeneous disease characterized by airway inflammation resulting from complex interactions between multiple hosts as well as environmental factors. As a chronic respiratory condition, asthma exerts a significant impact on patients and the healthcare system. Per the Global Initiative for Asthma (GINA), inhaled corticosteroids (ICS) with/without long-acting beta2-agonists (LABAs) should be used as the preferred controllers for the management of asthma. Despite a range of therapeutic options, many patients with asthma remain uncontrolled, resulting in an increased risk of hospitalization and emergency room visits and a worsened quality of life. Tiotropium (Spiriva®, Boehringer Ingelheim Pharmaceuticals, Inc; 1.25 µg, two puffs, once daily), delivered via the Respimat® inhaler (Boehringer Ingelheim Pharmaceuticals, Inc.), was the first long-acting muscarinic antagonist to be approved as an add-on maintenance treatment option for patients with asthma aged ≥6 years at GINA steps 4 and 5. By binding to the muscarinic receptors M1 and M3 in the bronchial airways, tiotropium antagonizes the action of acetylcholine, leading to smooth muscle relaxation and reduced mucus secretion.The efficacy and safety of tiotropium add-on to ICS±LABA maintenance treatment have been evaluated in randomized controlled trials (RCTs) involving patients with a range of asthma severities (mild, moderate, and severe) and across age groups (children, adolescents, and adults). Add-on tiotropium was found to be well tolerated and efficacious in all RCTs. Moreover, the findings from real-world studies complement results from RCTs, showing beneficial effects of tiotropium in reducing exacerbations, hospitalization, emergency room visits, and asthma worsening.In this review article, we discuss the pathophysiology of asthma and the role of tiotropium in the management of asthma from the perspective of a primary care physician.
Collapse
Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Ku-Lang Chang
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| |
Collapse
|
6
|
Aisanov Z, Khaltaev N. Management of cardiovascular comorbidities in chronic obstructive pulmonary disease patients. J Thorac Dis 2020; 12:2791-2802. [PMID: 32642187 PMCID: PMC7330365 DOI: 10.21037/jtd.2020.03.60] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is а highly prevalent, complex and heterogeneous clinical condition which is associated with significant concomitant diseases. COPD and cardiovascular diseases (CVDs) often coexist due to the high prevalence of each of these pathological conditions separately as well as the common risk factors (particularly smoking), mechanisms of interaction and influence of systemic inflammation. In addition, decreased pulmonary function in COPD is closely associated with an increased risk of congestive CVDs. One of the most important pathophysiological markers of COPD—lung hyperinflation—plays a significant role in the appearance of functional limitations of the pumping function of the heart, creating unfavorable conditions by exerting a compression effect on the heart muscle. The latter was confirmed by significant correlation between the COPD severity according to GOLD classification and the basic dimensions of the heart chambers. Several decades ago, the term “microcardia” was commonly used and indicated a radiological sign of emphysema. Some studies demonstrated a close relationship between the chance of occurrence of CVD and the severity of pulmonary dysfunction. Such an association has been demonstrated for the whole spectrum of CVD—including cerebrovascular disease, congestive heart failure (CHF) and rhythm disturbances—and was detected in the early stages of the disease. A large proportion of patients with mild and moderate COPD die due to CVD, which is much more likely than deaths in the same group due to respiratory insufficiency. COPD patients have a higher rate of hospitalization and death, the cause of which are coronary heart disease (CHD), stroke and CHF. Treatment of COPD today is mainly determined by national and international clinical guidelines, which should pay more attention to the problems of the treatment of COPD patients with comorbid conditions.
Collapse
Affiliation(s)
- Zaurbek Aisanov
- Pulmonology Department, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Nikolai Khaltaev
- WHO Global Coordination Mechanism for NCD Prevention and Control, WHO, Geneva, Switzerland
| |
Collapse
|
7
|
Association of tiotropium use and the risk of adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a meta-analysis of randomized controlled trials. Eur J Clin Pharmacol 2020; 76:795-805. [DOI: 10.1007/s00228-020-02853-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
|
8
|
Crim C, Gotfried M, Spangenthal S, Watkins M, Emmett A, Crawford C, Baidoo C, Castro-Santamaria R. A randomized, controlled, repeat-dose study of batefenterol/fluticasone furoate compared with placebo in the treatment of COPD. BMC Pulm Med 2020; 20:119. [PMID: 32366249 PMCID: PMC7199364 DOI: 10.1186/s12890-020-1153-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 04/20/2020] [Indexed: 12/11/2022] Open
Abstract
Background Batefenterol (BAT) is a bi-functional molecule with both muscarinic antagonist and β2-adrenoceptor agonist pharmacology. This Phase II, randomized, placebo-controlled, double-blind study evaluated the safety and tolerability of BAT 300 μg with fluticasone furoate (FF) 100 μg administered via the ELLIPTA inhaler (BAT/FF 300/100). Methods Subjects with stable chronic obstructive pulmonary disease were randomized 2:1 to receive BAT/FF 300/100 or placebo once daily for 6 weeks. The primary endpoint was change from baseline in 0–4-h weighted mean (WM) heart rate (HR, measured by electrocardiogram [ECG]) on Day 42. Other endpoints included WM and maximum 0–4-h corrected QT interval (ECG on Days 1, 28, and 42), HR measured by Holter monitoring (Day 42), and standard safety assessments. Study protocol was approved by an Investigational Review Board. Results Sixty-two patients were randomized and received ≥1 dose of study medication (BAT/FF 300/100 n = 42; placebo n = 20). Mean age was 62.5 years (standard deviation [SD] 8.17). Study completion rates were 83% (BAT/FF 300/100) and 100% (placebo). Screening mean (SD) post-bronchodilator percentage-predicted forced expiratory volume in 1 s was 57.57 (11.42) in the BAT/FF 300/100 group and 55.68 (14.03) in the placebo group. BAT/FF 300/100 was non-inferior to placebo for the primary endpoint, treatment difference: − 2.2 beats per minute (bpm), 95% confidence interval [CI]: − 6.2, 1.7). There were no clinically relevant differences between treatment groups in WM or maximum 0–4-h corrected QT interval, or mean HR based on Holter monitoring on Day 42 (BAT/FF 300/100: 76.3 bpm [SD 11.38]; placebo: 84.8 bpm [SD 9.87]). Adverse events (AEs) occurred in 38% (BAT/FF 300/100) and 35% (placebo) of patients. AEs in ≥2 subjects with BAT/FF 300/100 were dysgeusia (10%), diarrhea (7%), nasopharyngitis (7%), and cough (5%). AEs leading to discontinuation occurred in two subjects who received BAT/FF 300/100: post-treatment severe pneumonia (serious AE) and non-serious AEs of moderate vomiting and severe gastroenteritis; both were not considered drug-related. No deaths occurred. Conclusions Six weeks of BAT/FF 300/100 treatment was non-inferior to placebo for change from baseline in HR, with no new clinically relevant general or cardiovascular safety signals. Trial registration Clinicaltrials.gov: NCT02573870 (submitted October 12, 2015).
Collapse
Affiliation(s)
- Courtney Crim
- GSK, Research & Development, Research Triangle Park, NC, USA.
| | | | | | - Michael Watkins
- GSK, Research & Development, Research Triangle Park, NC, USA
| | | | - Catriona Crawford
- GSK, Global Medical, Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex, UK
| | - Charlotte Baidoo
- GSK, Clinical Statistics, Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex, UK
| | | |
Collapse
|
9
|
Fischer O, Hofmann J, Rampp H, Kaindl J, Pratsch G, Bartuschat A, Taudte RV, Fromm MF, Hübner H, Gmeiner P, Heinrich MR. Regiospecific Introduction of Halogens on the 2-Aminobiphenyl Subunit Leading to Highly Potent and Selective M3 Muscarinic Acetylcholine Receptor Antagonists and Weak Inverse Agonists. J Med Chem 2020; 63:4349-4369. [PMID: 32202101 DOI: 10.1021/acs.jmedchem.0c00297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Muscarinic M3 receptor antagonists and inverse agonists displaying high affinity and subtype selectivity over the antitarget M2 are valuable pharmacological tools and may enable improved treatment of chronic obstructive pulmonary disease (COPD), asthma, or urinary incontinence. On the basis of known M3 antagonists comprising a piperidine or quinuclidine unit attached to a biphenyl carbamate, 5-fluoro substitution was responsible for M3 subtype selectivity over M2, while 3'-chloro substitution substantially increased affinity through a σ-hole interaction. Resultantly, two piperidinyl- and two quinuclidinium-substituted biphenyl carbamates OFH243 (13n), OFH244 (13m), OFH3911 (14n), and OFH3912 (14m) were discovered, which display two-digit picomolar affinities with Ki values from 0.069 to 0.084 nM, as well as high selectivity over the M2 subtype (46- to 68-fold). While weak inverse agonistic properties were determined for the biphenyl carbamates 13m and 13n, neutral antagonism was observed for 14m and 14n and tiotropium under identical assay conditions.
Collapse
Affiliation(s)
- Oliver Fischer
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Josefa Hofmann
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Hannelore Rampp
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Jonas Kaindl
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Gerald Pratsch
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Amelie Bartuschat
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - R Verena Taudte
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Fahrstr. 17, 91054 Erlangen, Germany
| | - Martin F Fromm
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Fahrstr. 17, 91054 Erlangen, Germany
| | - Harald Hübner
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Peter Gmeiner
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| | - Markus R Heinrich
- Department of Chemistry and Pharmacy, Pharmaceutical Chemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany
| |
Collapse
|
10
|
Bhatt SP. Acute Exacerbations of Chronic Lung Disease: Cardiac Considerations. CARDIAC CONSIDERATIONS IN CHRONIC LUNG DISEASE 2020. [PMCID: PMC7282481 DOI: 10.1007/978-3-030-43435-9_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The importance of appropriately recognizing and managing patients with cardiovascular and pulmonary comorbidities is underscored by the poor outcomes described in complex comorbid patients. Patients with chronic obstructive pulmonary disease (COPD) have an increased risk, up to one-third greater than the general population, of cardiovascular comorbidities including hypertension and diabetes [1].
Collapse
Affiliation(s)
- Surya P. Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| |
Collapse
|
11
|
Aisanov ZR, Chuchalin AG, Kalmanova EN. [Chronic obstructive pulmonary disease and cardiovascular comorbidity]. ACTA ACUST UNITED AC 2019; 59:24-36. [PMID: 31526359 DOI: 10.18087/cardio.2572] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 11/18/2022]
Abstract
In recent years, a greater understanding of the heterogeneity and complexity of chronic obstructive pulmonary disease (COPD) has come from the point of view of an integrated clinical assessment of severity, pathophysiology, and the relationship with other pathologies. A typical COPD patient suffers on average 4 or more concomitant diseases and every day about a third of patients take from 5 to 10 different drugs. The mechanisms of the interaction of COPD and cardiovascular disease (CVD) include the effects of systemic inflammation, hyperinflation (hyperinflation) of the lungs and bronchial obstruction. The risk of developing CVD in patients with COPD is on average 2-3 times higher than in people of a comparable age in the general population, even taking into account the risk of smoking. The prevalence of coronary heart disease, heart failure, and rhythm disturbances among COPD patients is significantly higher than in the general population. The article discusses in detail the safety of prescribing various groups of drugs for the treatment of CVD in patients with COPD. Achieving success in understanding and managing patients with COPD and CVD is possible using an integrated multidisciplinary approach.
Collapse
Affiliation(s)
- Z R Aisanov
- Pirogov Russian National Research Medical University
| | - A G Chuchalin
- Pirogov Russian National Research Medical University
| | - E N Kalmanova
- Pirogov Russian National Research Medical University
| |
Collapse
|
12
|
Borin MT, Barnes CN, Darpo B, Pendyala S, Xue H, Bourdet DL. Revefenacin, a Long-Acting Muscarinic Antagonist, Does Not Prolong QT Interval in Healthy Subjects: Results of a Placebo- and Positive-Controlled Thorough QT Study. Clin Pharmacol Drug Dev 2019; 9:130-139. [PMID: 31468714 PMCID: PMC7004040 DOI: 10.1002/cpdd.732] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/24/2019] [Indexed: 12/22/2022]
Abstract
Revefenacin is a novel once‐daily, lung‐selective, long‐acting muscarinic antagonist developed as a nebulized inhalation solution for the maintenance treatment of chronic obstructive pulmonary disease. In a randomized, 4‐way crossover study, healthy subjects received a single inhaled dose of revefenacin 175 µg (therapeutic dose), revefenacin 700 µg (supratherapeutic dose), and placebo via standard jet nebulizer, and a single oral dose of moxifloxacin 400 mg (open‐label) in separate treatment periods. Electrocardiograms were recorded, and pharmacokinetic samples were collected serially after dosing. The primary end point was the placebo‐corrected change from baseline QT interval corrected for heart rate using Fridericia's formula, analyzed at each postdose time. Concentration‐QTc modeling was also performed. Following administration of revefenacin 175 and 700 µg, placebo‐corrected change from baseline QTcF (ΔΔQTcF) values were close to 0 at all times, with the largest mean ΔΔQTcF of 1.0 millisecond (95% confidence interval [CI], −1.2 to 3.1 milliseconds) 8 hours postdose and 1.0 millisecond (95%CI, −1.1 to 3.1 milliseconds) 1 hour postdose after inhalation of revefenacin 175 and 700 µg, respectively. Revefenacin did not have a clinically meaningful effect on heart rate (within ±5 beats per minute of placebo), or PR and QRS intervals (within ±3 and ±1 milliseconds of placebo, respectively). Using concentration‐QTc modeling, an effect of revefenacin > 10 milliseconds can be excluded within the observed plasma concentration range of up to ≈3 ng/mL. Both doses of revefenacin were well tolerated. These results demonstrate that revefenacin does not prolong the QT interval.
Collapse
Affiliation(s)
- Marie T Borin
- Theravance Biopharma US, Inc., South San Francisco, California, USA
| | - Chris N Barnes
- Theravance Biopharma US, Inc., South San Francisco, California, USA
| | - Borje Darpo
- ERT, previously iCardiac Technologies, Rochester, New York, USA
| | | | - Hongqi Xue
- ERT, previously iCardiac Technologies, Rochester, New York, USA
| | - David L Bourdet
- Theravance Biopharma US, Inc., South San Francisco, California, USA
| |
Collapse
|
13
|
Abstract
Given the high proportion of patients with asthma who remain uncontrolled despite controller treatment, there remains a need for the development of more effective treatment options with a proven safety and tolerability profile. Recently, asthma guidelines have evolved to incorporate new therapies, including long-acting muscarinic antagonists (LAMAs) and biologics. Here we focus on the safety profile of tiotropium, a LAMA, using data from the large-scale UniTinA-asthma® clinical trial program, which investigated the use of tiotropium in over 6000 patients with asthma who remained symptomatic despite receiving inhaled corticosteroids (ICS) maintenance therapy, with or without other adjunct therapies. The large number of patients included allows robust analysis of safety and tolerability. Overall, a similar incidence of patients reporting any adverse event (AE) was observed in the tiotropium (5 µg and 2.5 µg) and placebo groups. Asthma worsening, decreased peak expiratory flow, and upper respiratory tract infections were the most frequently reported AEs. Serious AEs (SAEs) and investigator-defined drug-related AEs were infrequently reported across all treatment groups, including the placebo group, and there were no deaths in any study. Reports of side effects typically associated with anticholinergic drugs, such as dry mouth and urinary retention, were either infrequent or not reported in children, adolescents or adults. The similar proportions of tiotropium- versus placebo-treated patients reporting AEs and SAEs in African-American and Japanese populations, as well as in elderly patients, contribute to the accumulating evidence of the safety and tolerability of tiotropium across broad ethnic and age populations.
Collapse
Affiliation(s)
- Daniel Dusser
- Service de Pneumologie, Hôpital Cochin, AP-HP, Université Paris Descartes, 27 Rue du Faubourg Saint-Jacques, Sorbonne Paris Cité, Paris, 75014, France
| | - Francine M Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine, University of Montréal, Montréal, Canada Research Centre, CHU Sainte-Justine, Montréal, Canada
| |
Collapse
|
14
|
Donohue JF, Feldman G, Sethi S, Barnes CN, Pendyala S, Bourdet D, Crater G. Cardiovascular safety of revefenacin, a once-daily, lung-selective, long-acting muscarinic antagonist for nebulized therapy of chronic obstructive pulmonary disease: Evaluation in phase 3 clinical trials. Pulm Pharmacol Ther 2019; 57:101808. [PMID: 31152911 DOI: 10.1016/j.pupt.2019.101808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/12/2019] [Accepted: 05/24/2019] [Indexed: 01/01/2023]
Abstract
The cardiovascular safety of revefenacin, an anticholinergic indicated for the maintenance treatment of patients with chronic obstructive lung disease (COPD), was evaluated in phase 3 trials in patients with moderate to very severe COPD. No clinically meaningful changes in 12-lead electrocardiogram recordings were observed with up to 52 weeks of once-daily revefenacin 88 or 175 μg. In a pooled analysis of Studies 0126 and 0127, the incidence of prolonged QT interval corrected for heart rate using the Fridericia correction formula (QTcF; >450 msec) for revefenacin 88 μg (n = 23, 5.6%) and revefenacin 175 μg (n = 23, 5.9%) was similar to that for placebo (n = 22, 5.3%). In Study 0128, the incidence of prolonged QTcF was similar in the revefenacin 175 μg (n = 25, 7.7%) and tiotropium (n = 26, 7.3%) groups and lower in the revefenacin 88 μg (n = 15, 4.2%) group. There were four major adverse cardiac events (MACEs) in Study 0126 (one, two, and one in the placebo, revefenacin 88 μg, and revefenacin 175 μg groups, respectively), no MACEs in Study 0127 and 26 MACEs in Study 0128 (9, 10 and 7 in the revefenacin 88 μg, revefenacin 175 μg and tiotropium groups, respectively). In Study 0128, only one MACE was considered possibly/probably related to revefenacin (atrial fibrillation in the revefenacin 175 μg group). Thus, revefenacin may provide beneficial nebulized therapy for patients with COPD without further elevating their risk of cardiovascular events.
Collapse
Affiliation(s)
- James F Donohue
- UNC School of Medicine, 130 Mason Farm Road, Chapel Hill, NC, 27514, USA.
| | - Gregory Feldman
- South Carolina Pharmaceutical Research, 151 Harold Fleming Court, Spartanburg, SC, 29303, USA.
| | - Sanjay Sethi
- University at Buffalo, State University of New York, 3495 Bailey Avenue, Buffalo, NY, 14215, USA.
| | - Chris N Barnes
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
| | - Srikanth Pendyala
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
| | - David Bourdet
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
| | - Glenn Crater
- Theravance Biopharma US, Inc., South San Francisco, 901 Gateway Boulevard, CA, 94080, USA.
| |
Collapse
|
15
|
Wise RA, Chapman KR, Scirica BM, Bhatt DL, Daoud SZ, Zetterstrand S, Reisner C, Gil EG. Effect of Aclidinium Bromide on Major Cardiovascular Events and Exacerbations in High-Risk Patients With Chronic Obstructive Pulmonary Disease: The ASCENT-COPD Randomized Clinical Trial. JAMA 2019; 321:1693-1701. [PMID: 31063575 PMCID: PMC6506885 DOI: 10.1001/jama.2019.4973] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 04/08/2019] [Indexed: 12/23/2022]
Abstract
Importance There is concern that long-acting muscarinic antagonists increase cardiovascular morbidity or mortality in patients with chronic obstructive pulmonary disease (COPD). Objective To determine the cardiovascular safety (noninferiority) and efficacy (superiority) of aclidinium bromide, 400 μg twice daily, in patients with COPD and cardiovascular disease or risk factors. Design, Setting, and Participants Multicenter, randomized, placebo-controlled, double-blind, parallel-design study conducted at 522 sites in North America. A total of 3630 patients with moderate to very severe COPD and either a history of cardiovascular disease or at least 2 atherothrombotic risk factors were randomized; follow-up occurred for up to 3 years until at least 122 major adverse cardiovascular events (MACE) occurred. The first patient was enrolled on October 16, 2013 and the last on August 22, 2016. The final patient completed follow-up on September 21, 2017. Interventions Patients were randomized to receive aclidinium (n = 1812) or placebo (n = 1818) by dry-powder inhaler, twice daily for up to 3 years. Main Outcomes and Measures The primary safety end point was time to first MACE over up to 3 years (hazard ratio [HR] 1-sided 97.5% CI noninferiority margin = 1.8). The primary efficacy end point was the annual COPD exacerbation rate during the first year of treatment. Secondary outcomes included an expanded MACE definition (time to first MACE or serious cardiovascular event of interest) and annual rate of exacerbations requiring hospitalization. Results Among 3589 patients analyzed (mean age, 67.2 years; 58.7% male), 2537 (70.7%) completed the study. Of these, 69 (3.9%) aclidinium and 76 (4.2%) placebo patients had a MACE (HR, 0.89; 1-sided 97.5% CI, 0-1.23); the expanded MACE definition included 168 (9.4%) aclidinium vs 160 (8.9%) placebo patients with events (HR, 1.03; 1-sided 97.5% CI, 0-1.28). Annual moderate to severe exacerbation rates (aclidinium, 0.44; placebo, 0.57; rate ratio, 0.78; 2-sided 95% CI, 0.68-0.89; P < .001) and rate of exacerbations requiring hospitalization (aclidinium, 0.07; placebo, 0.10; rate ratio, 0.65; 2-sided 95% CI, 0.48-0.89; P = .006) decreased significantly with aclidinium vs placebo. The most common adverse events were pneumonia (aclidinium, 109 events [6.1%]; placebo, 105 events [5.8%]), urinary tract infection (aclidinium, 93 events [5.2%]; placebo, 89 events [5.0%]), and upper respiratory tract infection (aclidinium, 86 events [4.8%]; placebo, 101 events [5.6%]). Conclusions and Relevance Among patients with COPD and increased cardiovascular risk, aclidinium was noninferior to placebo for risk of MACE over 3 years. The rate of moderate to severe COPD exacerbations was reduced over the first year. Trial Registration ClinicalTrials.gov Identifier: NCT01966107.
Collapse
Affiliation(s)
- Robert A. Wise
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Benjamin M. Scirica
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sami Z. Daoud
- AstraZeneca Research and Development Centre, Gaithersburg, Maryland
| | - Sofia Zetterstrand
- AstraZeneca Research and Development, Bioinformatics and Information Sciences, Mölndal, Sweden
| | - Colin Reisner
- AstraZeneca Research and Development Centre, Gaithersburg, Maryland
| | | |
Collapse
|
16
|
Rogliani P, Calzetta L, Matera MG, di Daniele N, Girolami A, Cazzola M, Ora J. Inhaled therapies and cardiovascular risk in patients with chronic obstructive pulmonary disease. Expert Opin Pharmacother 2019; 20:737-750. [PMID: 30707637 DOI: 10.1080/14656566.2019.1570133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) therapy includes a multi-dimensional approach, taking into account both symptoms of the patient and the number of acute exacerbations of COPD (AECOPDs). There are three main pharmaceutical classes currently available including long-acting muscarinic antagonists (LAMA), long-acting β2-agonists (LABA) and inhaled corticosteroids (ICS). COPD is a major risk factor for most cardiovascular diseases, and cardiac comorbidities are very common in COPD patients. Both LAMA and LABA have a considerable impact on cardiac function by stimulating cardiac β2-adrenergic receptors or inhibiting the heart M2 muscarinic receptors. ICS alone or in combination has never been associated with a real cardiovascular risk. AREAS COVERED This review explores the data published on the safety of COPD therapy and the implications for current pharmacotherapy. EXPERT OPINION Several studies have confirmed the good safety profile of bronchodilators available both in monotherapy and in association with other bronchodilators of different classes or with ICS despite the device used. Cardiovascular events in clinical trials are generally low and balanced between groups. The actual cardiovascular risk of fixed-dose combinations (FDCs) in an unselected COPD population will need to be investigated through post-marketing surveillance studies and observational studies.
Collapse
Affiliation(s)
- Paola Rogliani
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy.,b Division of Respiratory Medicine , University Hospital "Tor Vergata" , Rome , Italy
| | - Luigino Calzetta
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Maria Gabriella Matera
- c Department of Experimental Medicine , University of Campania Luigi Vanvitelli , Naples , Italy
| | - Nicola di Daniele
- d Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Andrea Girolami
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Mario Cazzola
- a Department of Experimental Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Josuel Ora
- b Division of Respiratory Medicine , University Hospital "Tor Vergata" , Rome , Italy
| |
Collapse
|
17
|
Ferguson GT, Buhl R, Bothner U, Hoz ADL, Voß F, Anzueto A, Calverley PMA. Safety of tiotropium/olodaterol in chronic obstructive pulmonary disease: pooled analysis of three large, 52-week, randomized clinical trials. Respir Med 2018; 143:67-73. [PMID: 30261995 DOI: 10.1016/j.rmed.2018.08.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/27/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND An extensive clinical trial program supports the efficacy and safety of tiotropium/olodaterol in chronic obstructive pulmonary disease (COPD). We examined the safety of tiotropium/olodaterol compared with tiotropium in a large population of patients, focusing on cardiovascular and respiratory events. METHODS Patients (n = 9942) who received once-daily tiotropium/olodaterol 5/5 μg or tiotropium 5 μg (via Respimat®) in TONADO 1 & 2 and DYNAGITO were included. The number of patients and exposure-adjusted rate of events are presented for adverse events (AEs), serious AEs (SAEs), AEs leading to discontinuation, and cardiovascular and respiratory events. FINDINGS Fewer patients discontinued due to AEs with tiotropium/olodaterol (5.9%) versus tiotropium (7.9%; rate ratio [RR] 0.72; 95% confidence interval [CI] 0.62-0.84). There was no significant difference in the incidence of AEs, SAEs, cardiovascular AEs or central nervous system vascular AEs between treatments. Incidences of major adverse cardiovascular events (MACE) were 2.11 per 100 patient-years with tiotropium/olodaterol and 2.22 with tiotropium (RR 0.95; 95% CI 0.72-1.25), and incidences of fatal MACE (including death with undetermined cause) were 0.91 and 1.00 per 100 patient-years with tiotropium/olodaterol and tiotropium, respectively (RR 0.91; 95% CI 0.60-1.37). Respiratory AEs were generally balanced between treatment groups. CONCLUSIONS These results provide robust evidence that the benefits of tiotropium/olodaterol versus tiotropium are not at the expense of an increased risk of safety events. The combination is a suitable option for patients with COPD, even in the presence of cardiovascular risk factors. CLINICAL TRIALS REGISTRATION clinicaltrials. gov (TONADO 1 and 2: NCT01431274, NCT01431287; DYNAGITO: NCT02296138).
Collapse
Affiliation(s)
- Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Suite A, 29255 W 10 Mile Road, Farmington Hills, MI, 48336, USA.
| | - Roland Buhl
- Johannes Gutenberg University Hospital Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Ulrich Bothner
- TA/Respiratory Biosimilars Medicine, Boehringer Ingelheim International GmbH, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
| | - Alberto de la Hoz
- TA/Respiratory Biosimilars Medicine, Boehringer Ingelheim International GmbH, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
| | - Florian Voß
- Biostatistics & Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
| | - Antonio Anzueto
- Department of Pulmonary Medicine and Critical Care, University of Texas Health Sciences Center and South Texas Veterans Health Care System, 4242 Medical Drive, Suite 111E, San Antonio, TX, 78229, USA.
| | - Peter M A Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK.
| |
Collapse
|
18
|
LaForce C, Derom E, Bothner U, Kloer IM, Trampisch M, Buhl R. Long-term safety of tiotropium/olodaterol Respimat ® in patients with moderate-to-very severe COPD and renal impairment in the TONADO ® studies. Int J Chron Obstruct Pulmon Dis 2018; 13:1819-1831. [PMID: 29910611 PMCID: PMC5987861 DOI: 10.2147/copd.s161489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The safety, lung function efficacy, and symptomatic benefits of combined tiotropium and olodaterol in patients with COPD were established in the 1-year TONADO® studies (NCT01431274; NCT01431287). As tiotropium is predominantly excreted by the kidneys, the long-term safety profile of tiotropium/olodaterol was investigated in patients with renal impairment in a prespecified safety analysis of the TONADO studies. Methods These were 2 replicate, randomized, double-blind, parallel-group, 52-week Phase III studies that assessed tiotropium/olodaterol compared with tiotropium or olodaterol alone (all via Respimat®) in patients with moderate-to-very severe COPD. In this analysis, renal impairment was defined as mild (creatinine clearance [CLcr] 60–89 mL/min), moderate (CLcr 30–59 mL/min) or severe (CLcr 15–29 mL/min). Adverse events (AEs) were pooled from both studies. Results Of 3,041 patients included in this analysis, 1,333 (43.8%) had mild, 404 (13.3%) had moderate, and 5 (0.2%) had severe renal impairment; these were distributed equally between treatment groups. Almost one-quarter of all treated patients (23.4%) had a history of cardiac disorder, 45.6% had hypertension, and 13.3% had glucose metabolism disorders, including diabetes. AEs with olodaterol, tiotropium, and tiotropium/olodaterol occurred in 75.1%, 70.8%, and 72.0% of patients with no renal impairment, 75.7%, 74.0%, and 73.3% with mild renal impairment, and 84.3%, 79.5%, and 79.7% with moderate renal impairment, respectively. There was no notable effect of renal impairment on the proportion of patients with an AE, and no differences were observed between tiotropium/olodaterol versus the monocomponents. There was no difference in the incidence of major adverse cardiac events, renal and urinary tract AEs, or potential anticholinergic effects with increasing severity of renal impairment. Conclusion Over half the patients enrolled in the TONADO studies had renal impairment, and there was a high level of pre-existing cardiovascular comorbidity. The safety and tolerability of tiotropium/olodaterol is comparable to the monocomponents, irrespective of the level of renal impairment.
Collapse
Affiliation(s)
| | - Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ulrich Bothner
- Pharmacovigilance, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Isabel M Kloer
- Pharmacovigilance, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Matthias Trampisch
- Biostatistics & Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| |
Collapse
|
19
|
Matera MG, Calzetta L, Puxeddu E, Rogliani P, Cazzola M. A safety comparison of LABA+LAMA vs LABA+ICS combination therapy for COPD. Expert Opin Drug Saf 2018; 17:509-517. [DOI: 10.1080/14740338.2018.1448786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Maria Gabriella Matera
- Department of Experimental Medicine, Unit of Pharmacology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luigino Calzetta
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ermanno Puxeddu
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
| |
Collapse
|
20
|
Wise RA, Chapman KR, Scirica BM, Schoenfeld DA, Bhatt DL, Daoud SZ, Seoane B, Reisner C, Garcia Gil E. Long-Term Evaluation of the Effects of Aclidinium Bromide on Major Adverse Cardiovascular Events and COPD Exacerbations in Patients with Moderate to Very Severe COPD: Rationale and Design of the ASCENT COPD Study. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2018; 5:5-15. [PMID: 29629400 PMCID: PMC5870740 DOI: 10.15326/jcopdf.5.1.2017.0149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 01/21/2023]
Abstract
Introduction: Chronic obstructive pulmonary disease (COPD) is a heterogeneous illness characterized by persistent airflow obstruction and exacerbations. Patients typically experience a decline in lung function, increasingly impaired health-related quality of life, and high mortality. Poor lung function and exacerbations are associated with an increased risk of cardiovascular (CV) and cerebrovascular events, and approximately 30% of patients with COPD die from CV‑related disease. Treatment with inhaled long-acting bronchodilators, such as long-acting muscarinic antagonists (LAMAs), is recommended; however, some studies have suggested that LAMAs may increase the risk of CV events. As patients with CV and cerebrovascular conditions are often excluded from clinical trials, an evaluation of the safety of COPD treatments in an at-risk population is vital. Aclidinium bromide is a LAMA approved for the long-term maintenance treatment of COPD. Methods and Objectives: The Phase 4, multicenter, double-blind, randomized, placebo-controlled, parallel-group Aclidinium Bromide on Long-Term Cardiovascular Safety and COPD Exacerbations in PatieNTs with Moderate to Very Severe COPD (ASCENT COPD) study (NCT01966107) is being conducted at 500 sites in the United States and Canada. The primary objectives are to evaluate the long-term effects of twice-daily aclidinium bromide 400 µg on CV safety and exacerbations in patients with moderate to very severe COPD with a history of cerebrovascular, coronary, or peripheral artery disease, or the presence of ≥2 atherothrombotic risk factors. The primary safety and efficacy variables are time to first major adverse CV event (MACE) (on-study analysis) and rate of moderate to severe COPD exacerbations during the first year of treatment (on-treatment analysis), respectively. The study will be terminated after approximately 122 MACE have occurred.
Collapse
Affiliation(s)
- Robert A. Wise
- 1-Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Benjamin M. Scirica
- 3-Brigham and Women’s Hospital, Boston, Massachusetts
- 4-Harvard Medical School, Boston, Massachusetts
| | | | - Deepak L. Bhatt
- 3-Brigham and Women’s Hospital, Boston, Massachusetts
- 4-Harvard Medical School, Boston, Massachusetts
| | - Sami Z. Daoud
- 5-AstraZeneca Research &Development Center, Gaithersburg, Maryland
| | - Beatriz Seoane
- 6-AstraZeneca Research & Development Centre, Barcelona, Spain
| | - Colin Reisner
- 5-AstraZeneca Research &Development Center, Gaithersburg, Maryland
| | | |
Collapse
|
21
|
Rogliani P, Brusasco V, Fabbri L, Ungar A, Muscianisi E, Barisone I, Corsini A, De Angelis G. Multidimensional approach for the proper management of a complex chronic patient with chronic obstructive pulmonary disease. Expert Rev Respir Med 2017; 12:103-112. [PMID: 29241393 DOI: 10.1080/17476348.2018.1417041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is frequently associated with comorbidities occurring either independently or as consequences of COPD. Areas covered: This review examines the interactions between the pathophysiology of COPD and the most frequent comorbidities, and highlights the need for multidimensional clinical strategies to manage COPD patients with comorbidities. Expert commentary: Most COPD patients need to be approached in a complex and multifactorial scenario. The diagnosis of COPD is necessarily based on the presence of chronic respiratory symptoms and poorly reversible airflow obstruction, but exacerbations and comorbidities need to be considered in the evaluation of disease severity and prognosis in individual patients. More importantly, defining the precise relationship between COPD and comorbidities for each patient is the basis for a correct therapeutic approach.
Collapse
Affiliation(s)
- Paola Rogliani
- a Department of Experimental Medicine and Surgery , University of Rome "Tor Vergata" , Rome , Italy
| | - Vito Brusasco
- b Department of Internal Medicine , University of Genoa , Genova , Italy
| | - Leonardo Fabbri
- c Department of Endocrinology, Metabolism and Geriatric , Sant'Agostino Hospital , Modena , Italy
| | - Andrea Ungar
- d Geriatric and Intensive Care Medicine , AO Careggi and University of Florence , Florence , Italy
| | - Elisa Muscianisi
- e Novartis Farma Spa, Respiratory Franchise , Origgio , VA , Italy
| | - Ilaria Barisone
- e Novartis Farma Spa, Respiratory Franchise , Origgio , VA , Italy
| | - Alberto Corsini
- f Department of Pharmacological and Biomolecular Sciences , University of Milan , Milan , Italy.,g Multimedica IRCCS , Milan Italy
| | - Giuseppe De Angelis
- h Department of Cardiovascular Medicine , University of Milan , Milan , Italy
| |
Collapse
|
22
|
Corrao S, Brunori G, Lupo U, Perticone F. Effectiveness and safety of concurrent beta-blockers and inhaled bronchodilators in COPD with cardiovascular comorbidities. Eur Respir Rev 2017; 26:160123. [PMID: 28794142 PMCID: PMC9488816 DOI: 10.1183/16000617.0123-2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/26/2017] [Indexed: 12/28/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the most common chronic respiratory disease and its prevalence is increasing worldwide, in both industrialised and developing countries. Its prevalence is ∼5% in the general population and it is the fourth leading cause of death worldwide. COPD is strongly associated with cardiovascular diseases; in fact, ∼64% of people suffering from COPD are treated for a concomitant cardiovascular disease and approximately one in three COPD patients die as a consequence of cardiovascular diseases.Inhaled bronchodilators might have adverse cardiovascular effects, including ischaemic events and arrhythmias, and beta-blockers might adversely influence the respiratory symptoms and the response to bronchodilators. For these reasons, it is important to know the safety profiles and the possible interactions between these two classes of drug, in order to prescribe them with greater awareness.In this article, we review the literature about the epidemiology of COPD, its association with cardiovascular diseases, and the safety of concurrent use of inhaled bronchodilators and beta-blockers, as a tool for improving the approach to complex therapies in clinical practice.
Collapse
Affiliation(s)
- Salvatore Corrao
- Dept of Internal Medicine, National Relevance and High Specialization Hospital Trust, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy
- Centre of Research for Effectiveness and Appropriateness in Medicine (CREAM), DiBiMIS, University of Palermo, Palermo, Italy
| | - Giuseppe Brunori
- Dept of Internal Medicine, National Relevance and High Specialization Hospital Trust, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy
| | - Umberto Lupo
- Dept of Internal Medicine, National Relevance and High Specialization Hospital Trust, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy
| | - Francesco Perticone
- Dept of Medical and Surgical Sciences, University Magna Græcia, Catanzaro, Italy
| |
Collapse
|
23
|
Roversi S, Fabbri LM, Sin DD, Hawkins NM, Agustí A. Chronic Obstructive Pulmonary Disease and Cardiac Diseases. An Urgent Need for Integrated Care. Am J Respir Crit Care Med 2017; 194:1319-1336. [PMID: 27589227 DOI: 10.1164/rccm.201604-0690so] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a global health issue with high social and economic costs. Concomitant chronic cardiac disorders are frequent in patients with COPD, likely owing to shared risk factors (e.g., aging, cigarette smoke, inactivity, persistent low-grade pulmonary and systemic inflammation) and add to the overall morbidity and mortality of patients with COPD. The prevalence and incidence of cardiac comorbidities are higher in patients with COPD than in matched control subjects, although estimates of prevalence vary widely. Furthermore, cardiac diseases contribute to disease severity in patients with COPD, being a common cause of hospitalization and a frequent cause of death. The differential diagnosis may be challenging, especially in older and smoking subjects complaining of unspecific symptoms, such as dyspnea and fatigue. The therapeutic management of patients with cardiac and pulmonary comorbidities may be similarly challenging: bronchodilators may have cardiac side effects, and, vice versa, some cardiac medications should be used with caution in patients with lung disease. The aim of this review is to summarize the evidence of the relationship between COPD and the three most frequent and important cardiac comorbidities in patients with COPD: ischemic heart disease, heart failure, and atrial fibrillation. We have chosen a practical approach, first summarizing relevant epidemiological and clinical data, then discussing the diagnostic and screening procedures, and finally evaluating the impact of lung-heart comorbidities on the therapeutic management of patients with COPD and heart diseases.
Collapse
Affiliation(s)
- Sara Roversi
- 1 Department of Metabolic Medicine, University of Modena and Reggio Emilia and Sant'Agostino Estense Hospital, Modena, Italy
| | - Leonardo M Fabbri
- 1 Department of Metabolic Medicine, University of Modena and Reggio Emilia and Sant'Agostino Estense Hospital, Modena, Italy
| | | | - Nathaniel M Hawkins
- 3 Division of Cardiology, Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Alvar Agustí
- 4 Thorax Institute, Hospital Clinic in Barcelona, University of Barcelona, Barcelona, Spain
| |
Collapse
|
24
|
Abstract
Evidence-based guidelines recommend inhaled long-acting anti-muscarinic agents (LAMAs) as first-line maintenance therapy for symptomatic patients with COPD. Several LAMAs are now available for use either as monotherapy or in combination with other COPD medications, including long-acting β2-agonists (LABAs) or inhaled corticosteroids (ICS). The efficacy and long-term safety of these medications have been evaluated in multiple clinical trials and real-life studies. This review evaluates the evidence available on the safety of existing LAMAs alone or in combination with LABAs and ICS in patients with COPD.
Collapse
Affiliation(s)
- Nicola A Hanania
- a Section of Pulmonary and Critical Care Medicine , Baylor College of Medicine , Houston , TX , USA
| | - Suzanne C Lareau
- b College of Nursing , University of Colorado Denver , Aurora , CO , USA
| | - Barbara P Yawn
- c Department of Family and Community Health , University of Minnesota , Minneapolis , MN , USA
| |
Collapse
|
25
|
Halpin DM, Kaplan AG, Russell RK. Why choose tiotropium for my patient? A comprehensive review of actions and outcomes versus other bronchodilators. Respir Med 2017; 128:28-41. [PMID: 28610667 DOI: 10.1016/j.rmed.2017.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) and asthma are leading causes of morbidity and mortality. This narrative review provides an appraisal of the pharmacological and clinical characteristics of tiotropium in COPD and asthma, and examines how these compare with other long-acting bronchodilators. The evidence base is placed into context by relating it to factors affecting clinicians' choice of therapy. MAIN FINDINGS Desirable attributes of a long-acting muscarinic antagonist (LAMA) maintenance therapy include effective pharmacological bronchodilation, improved lung function, exacerbation efficacy, and positive effects on symptom control, exercise capacity and quality of life across a broad patient population. Tolerability and convenience of use are also important for patient well-being and treatment adherence. Tiotropium shows higher affinity for muscarinic receptors than ipratropium, and prolonged binding to the M3 receptor compared with other LAMAs. In COPD, tiotropium has demonstrated improved lung function and exacerbation prevention compared with placebo or long-acting β2-agonists, similar exacerbation efficacy to other LAMAs, and enhanced symptom control and health status versus placebo. UniTinA-asthma® showed the benefits of add-on tiotropium in patients with uncontrolled mild to moderate and severe asthma. Tiotropium is well tolerated, with an incidence of adverse events similar to placebo, except for known infrequent side effects of anticholinergics. Tiotropium HandiHaler® and Respimat® augment inhaler choice in COPD. PRINCIPAL CONCLUSIONS With over 10 years' prescribing history and 50 million patient-years of use, tiotropium has the benefit of a more extensive clinical evidence base than other long-acting bronchodilators, with demonstrated efficacy and safety in COPD and symptomatic asthma.
Collapse
Affiliation(s)
- David M Halpin
- Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, United Kingdom.
| | - Alan G Kaplan
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, ON M5G 1V7, Canada.
| | - Richard K Russell
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DS, United Kingdom.
| |
Collapse
|
26
|
Wise RA, Kowey PR, Austen G, Mueller A, Metzdorf N, Fowler A, McGarvey LP. Discordance in investigator-reported and adjudicated sudden death in TIOSPIR. ERJ Open Res 2017; 3:00073-2016. [PMID: 28344980 PMCID: PMC5358526 DOI: 10.1183/23120541.00073-2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 01/08/2017] [Indexed: 12/29/2022] Open
Abstract
Accurate and consistent determination of cause of death is challenging in chronic obstructive pulmonary disease (COPD) patients. TIOSPIR (N=17 135) compared the safety and efficacy of tiotropium Respimat 5/2.5 µg with HandiHaler 18 µg in COPD patients. All-cause mortality was a primary end-point. A mortality adjudication committee (MAC) assessed all deaths. We aimed to investigate causes of discordance in investigator-reported and MAC-adjudicated causes of death and their impact on results, especially cardiac and sudden death. The MAC provided independent, blinded assessment of investigator-reported deaths (n=1302) and assigned underlying cause of death. Discordance between causes of death was assessed descriptively (shift tables). There was agreement between investigator-reported and MAC-adjudicated deaths in 69.4% of cases at the system organ class level. Differences were mainly observed for cardiac deaths (16.4% investigator, 5.1% MAC) and deaths assigned to general disorders including sudden death (17.4% investigator, 24.6% MAC). Reasons for discrepancies included investigator attribution to the immediate (e.g. myocardial infarction (MI)) over the underlying cause of death (e.g. COPD) and insufficient information for a definitive cause. Cause-specific mortality varies in COPD, depending on the method of assignment. Sudden death, witnessed and unwitnessed, is common in COPD and often attributed to MI without supporting evidence. Investigator-attributed causes of death may lead to unreliable estimates of cause-specific mortality in COPDhttp://ow.ly/uzt9308TePH
Collapse
Affiliation(s)
- Robert A Wise
- Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter R Kowey
- Division of Cardiology, Lankenau Heart Institute and Jefferson Medical College, Wynnewood, PA, USA
| | - George Austen
- Global Biostatistics and Data Sciences, Boehringer Ingelheim Ltd, Bracknell, UK
| | - Achim Mueller
- Global Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH Co & KG, Biberach, Germany
| | - Norbert Metzdorf
- Clinical Development and Medical Affairs, Boehringer Ingelheim Pharma GmbH Co & KG, Ingelheim am Rhein, Germany
| | - Andy Fowler
- Dept of Medical Affairs, Boehringer Ingelheim Pharma Ltd, Bracknell, UK
| | - Lorcan P McGarvey
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| |
Collapse
|
27
|
Cazzola M, Calzetta L, Rogliani P, Matera MG. Tiotropium formulations and safety: a network meta-analysis. Ther Adv Drug Saf 2017; 8:17-30. [PMID: 28203364 PMCID: PMC5298465 DOI: 10.1177/2042098616667304] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Tiotropium is now delivered via two different inhaler devices: the original Handihaler 18 μg once daily, which uses a powder formulation; and the newer Respimat Soft Mist Inhaler (SMI) 5 μg once daily. It has been questioned whether the two devices can be assumed to have the same safety profile, although the TIOSPIR trial showed that tiotropium when administered via Respimat SMI 5 μg is not less safe than Handihaler 18 μg. Therefore, we have carried out a safety evaluation of tiotropium Handihaler 18 µg versus tiotropium Respimat SMI 5 µg and 2.5 µg, via systematic review and network meta-analysis of the currently available clinical evidence. The results of our meta-analysis with an extremely large number of patients analysed demonstrate that the safety profile of tiotropium HandiHaler is generally superior to that of tiotropium Respimat SMI, although no statistical difference was detected between these two devices. However, the SUCRA analysis favoured tiotropium Respimat SMI with regards to serious adverse events (AEs). We do not believe that using Respimat SMI rather that HandiHaler exposes patients to higher risks of real AEs. Rather, we believe that there may be a different cardiovascular (CV) response to muscarinic receptors blockage in individual patients. Therefore, it will be essential to make all possible efforts to proactively identify patients at increased risk of CV AEs when treated with tiotropium or another antimuscarinic drug.
Collapse
Affiliation(s)
- Mario Cazzola
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Luigino Calzetta
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paola Rogliani
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | | |
Collapse
|
28
|
Kardos P, Worsley S, Singh D, Román-Rodríguez M, Newby DE, Müllerová H. Randomized controlled trials and real-world observational studies in evaluating cardiovascular safety of inhaled bronchodilator therapy in COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:2885-2895. [PMID: 27932872 PMCID: PMC5135074 DOI: 10.2147/copd.s118867] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Long-acting muscarinic antagonist (LAMA) or long-acting β2-agonist (LABA) bronchodilators and their combination are recommended for the maintenance treatment of chronic obstructive pulmonary disease (COPD). Although the efficacy of LAMAs and LABAs has been well established through randomized controlled trials (RCTs), questions remain regarding their cardiovascular (CV) safety. Furthermore, while the safety of LAMA and LABA monotherapy has been extensively studied, data are lacking for LAMA/LABA combination therapy, and the majority of the studies that have reported on the CV safety of LAMA/LABA combination therapy were not specifically designed to assess this. Evaluation of CV safety for COPD treatments is important because many patients with COPD have underlying CV comorbidities. However, severe CV and other comorbidities are often exclusion criteria for RCTs, contributing to a lack in external validity and generalizability. Real-world observational studies are another important tool to evaluate the effectiveness and safety of COPD therapies in a broader population of patients and can improve upon the external validity limitations of RCTs. We examine what is already known regarding the CV and cerebrovascular safety of LAMA/LABA combination therapy from RCTs and real-world observational studies, and explore the advantages and limitations of data derived from each study type. We also describe an ongoing prospective, observational, comparative post-authorization safety study of a LAMA/LABA combination therapy (umeclidinium/vilanterol) and LAMA monotherapy (umeclidinium) versus tiotropium, with a focus on the relative merits of the study design.
Collapse
Affiliation(s)
- Peter Kardos
- Group Practice and Respiratory, Allergy and Sleep Unit, Red Cross Maingau Hospital, Frankfurt, Germany
| | | | - Dave Singh
- University of Manchester, Medicines Evaluation Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Miguel Román-Rodríguez
- Primary Care Respiratory Research Unit, Instituto de Investigación Sanitaria de Palma IdisPa, Palma de Mallorca, Spain
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
| | | |
Collapse
|
29
|
Ruiz-Laiglesia F, Garcés-Horna V, Formiga F. Comprehensive therapeutic approach for patients with heart failure and comorbidity. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2015.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
30
|
Callejas González FJ, Genovés Crespo M, Cruz Ruiz J, Godoy Mayoral R, Agustín Martínez FJ, Martínez García AJ, Tárraga López PJ. UPLIFTstudy -understanding potential long-term impacts on function with tiotropium - and sub-analyses. Bibliographic resume of the obtained results. Expert Rev Respir Med 2016; 10:1023-33. [DOI: 10.1080/17476348.2016.1188693] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
31
|
Schmiedl S, Thürmann P, Fischer R, Rottenkolber D, Rottenkolber M. Response to Wise et al. (Tiotropium safety in real life populations). Br J Clin Pharmacol 2016; 82:564-5. [PMID: 27197733 DOI: 10.1111/bcp.12970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/08/2016] [Accepted: 04/09/2016] [Indexed: 01/01/2023] Open
Affiliation(s)
- Sven Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten.,Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten.,Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal
| | | | - Dominik Rottenkolber
- Institute of Health Economics and Management, Ludwig-Maximilians-Universitaet Muenchen, Munich.,Helmholtz Zentrum Muenchen - German Research Center for Environmental Health, Member of the German Center for Lung Research, Neuherberg
| | - Marietta Rottenkolber
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians-Universitaet Muenchen, Munich.,Diabetes Research Group, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| |
Collapse
|
32
|
Wise R, Anzueto A, Dahl R, Dusser D, Calverley P. Tiotropium safety in 'real-world' populations: Response to Schmiedl, et al. in the British Journal of Clinical Pharmacology. Br J Clin Pharmacol 2016; 82:562-3. [PMID: 27197835 PMCID: PMC4972173 DOI: 10.1111/bcp.12972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/23/2016] [Indexed: 01/17/2023] Open
Affiliation(s)
- Robert Wise
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio Anzueto
- University of Texas and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Ronald Dahl
- Odense University Hospital, Odense C, Denmark
| | - Daniel Dusser
- Service de Pneumologie Hôpital Cochin, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Peter Calverley
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| |
Collapse
|
33
|
Defining a COPD composite safety endpoint for demonstrating efficacy in clinical trials: results from the randomized, placebo-controlled UPLIFT® trial. Respir Res 2016; 17:48. [PMID: 27141828 PMCID: PMC4855862 DOI: 10.1186/s12931-016-0361-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/19/2016] [Indexed: 12/15/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) clinical trials evaluating hard endpoints (mortality, hospitalized exacerbations) require a large number of subjects and prolonged observational periods. We hypothesized that a composite endpoint of respiratory outcomes (CERO) can help evaluate safety and benefit in COPD trials. Methods Retrospective analysis of 5992 patients enrolled in the 4-year UPLIFT® trial, a randomized trial of tiotropium versus placebo in patients with moderate-to-severe COPD. Patients were permitted to continue using their usual COPD medications except for other anticholinergics. The CERO included deaths, respiratory failure, hospitalized exacerbations, and trial dropout due to COPD worsening. The incidence rates (IRs) per 100 patient-years and risk ratios (RRs and 95 % CI) were determined at years 1 to 4. The effect of treatments on CERO was similarly assessed. A power analysis helped calculate the sample size needed to achieve outcome differences between treatments. Results The CERO IRs at years 1 to 4 for tiotropium versus placebo were 16, 13, 11, and 11, and 21, 16, 14, and 13, respectively. The RRs of CERO between tiotropium and placebo at the same time points were: RR-year 0.76 (0.67, 0.86), 0.80 (0.72, 0.88), 0.81 (0.74, 0.89), and 0.84 (0.77, 0.92). Using the IRs and RRs, the sample size (alpha = 0.05 two-sided, 90 % power) for studies of 1, 2, 3, and 4 years would be 1546, 1392, 1216, and 1504 per treatment group, respectively, with 575, 810, 930, 1383 required events, respectively, for hypothetical, event-driven studies. Conclusions A composite endpoint incorporating relatively infrequent serious or significant COPD-related safety outcomes could be useful in clinical trials. In UPLIFT®, CERO events were significantly reduced in patients receiving tiotropium compared with placebo. Trial registration NCT00144339. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0361-4) contains supplementary material, which is available to authorized users.
Collapse
|
34
|
Kim MY, Song WJ, Cho SH. Pharmacotherapy in the management of asthma in the elderly: a review of clinical studies. Asia Pac Allergy 2016; 6:3-15. [PMID: 26844215 PMCID: PMC4731478 DOI: 10.5415/apallergy.2016.6.1.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 01/12/2016] [Indexed: 12/29/2022] Open
Abstract
Asthma in the elderly is a disease with emerging concern. Despite some recent advances in our understanding of epidemiology and pathophysiology, there is a considerable lack of clinical evidence specific to elderly patients. Currently available high quality clinical evidence has been mostly obtained from younger adults, but rarely from elderly patients. Under-representation of elderly patients in previous randomized trials may have been due to being, old age, or having comorbidities. Thus, a question may be raised whether current clinical evidence could be well generalized into elderly patients. Further clinical trials should address clinical issues raised in elderly population. In this review, we aimed to overview the efficacy and safety of pharmacological management, and also to summarize the literature relevant to elderly asthma.
Collapse
Affiliation(s)
- Mi-Yeong Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan 47392, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
| |
Collapse
|
35
|
Chapman KR, Beck E, Alcaide D, Garcia Gil E. Overall and Cardiovascular Safety of Aclidinium Bromide in Patients With COPD: A Pooled Analysis of Six Phase III, Placebo-Controlled, Randomized Studies. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2015; 3:435-445. [PMID: 28848864 PMCID: PMC5559124 DOI: 10.15326/jcopdf.3.1.2015.0148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/30/2015] [Indexed: 11/21/2022]
Abstract
Background: Aclidinium bromide, an M3-receptor-selective, twice-daily (BID), long-acting muscarinic antagonist, is rapidly hydrolyzed in human plasma, resulting in low systemic exposure and urinary excretion. We evaluated the overall and cardiovascular (CV) safety of aclidinium in patients with moderate to severe chronic obstructive pulmonary disease (COPD) by pooling data from 6 randomized, double-blind, placebo-controlled, parallel-group studies of ≥1 month's duration. METHODS Patients were current/former smokers aged ≥40 years with no history of clinically significant CV conditions. Treatment was administered (morning and evening) via GenuairTM/Pressair.®a Adverse events (AEs), major adverse CV events (MACE), cardiac and cerebrovascular AEs, and serious AEs (SAEs) were analyzed. Results: The pooled population included 2781 patients (aclidinium: n=1529; placebo: n=1252). The incidence of AEs was similar with aclidinium (53.5%) and placebo (55.4%), as was the incidence of cardiac (aclidinium: 5.0%; placebo: 4.4%) and cerebrovascular (aclidinium: 0.4%; placebo: 0.5%) events. The incidence of MACE was low (AEs: 0.7%; SAEs: 0.5%) and comparable between groups. The incidence of cardiac and cerebrovascular events was similar for patients with CV risk factors with aclidinium and placebo (rate ratio [RR] [95 %confidence interval (CI)]=1.01[.074, 1.39]). In patients with mild to severe renal impairment, the incidence of cardiac events was similar between groups (RR [95% CI]=0.87 [0.56, 1.36]). Conclusion: Aclidinium 400µg BID has a good safety profile and this pooled analysis found no evidence of increased CV or cerebrovascular risk compared with placebo in patients with moderate to severe COPD. Further studies are needed in high-risk patients.
Collapse
Affiliation(s)
- Kenneth R. Chapman
- Asthma and Airway Centre, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Ekkehard Beck
- Institut für Gesundheitsförderung GmbH, Rüdersdorf, Germany
| | | | - Esther Garcia Gil
- Institut für Gesundheitsförderung GmbH, Rüdersdorf, Germany
- R and D Centre, AstraZeneca PLC, Barcelona, Spain
| |
Collapse
|
36
|
Ruiz-Laiglesia FJ, Garcés-Horna V, Formiga F. Comprehensive therapeutic approach for patients with heart failure and comorbidity. Rev Clin Esp 2015; 216:323-30. [PMID: 26552747 DOI: 10.1016/j.rce.2015.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 09/28/2015] [Indexed: 01/11/2023]
Abstract
The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype». Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimised and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care.
Collapse
Affiliation(s)
- F J Ruiz-Laiglesia
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón, Zaragoza, España.
| | - V Garcés-Horna
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón, Zaragoza, España
| | - F Formiga
- Departamento de Medicina Interna, Hospital Universitario de Bellvitge. Instituto de Investigación Biomédica de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| |
Collapse
|
37
|
Tashkin DP. The safety of anticholinergic bronchodilators for the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Saf 2015; 14:1759-72. [PMID: 26401729 DOI: 10.1517/14740338.2015.1093621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Poorly absorbable quaternary ammonium-inhaled muscarinic antagonists both as the short-acting ipratropium and as long-acting (12 - 24 h) agents (tiotropium, glycopyrronium, aclidinium and umeclidinium) have all demonstrated statistically and clinically significant efficacy in chronic obstructive pulmonary disease compared with placebo. However, controversy has arisen concerning the safety of this class of agents principally regarding their association with both fatal and nonfatal cardiovascular toxicity. AREAS COVERED The safety of both ipratropium and the long-acting muscarinic antagonists is reviewed with a major emphasis on potential cardiovascular toxicity, based on published clinical trials data and results of analyses of pooled data, meta-analyses, and observational studies. Since glycopyrronium, aclidinium, and umeclidinium have become available only relatively recently, more emphasis will be placed on the more extensive literature concerning the safety of the older anticholinergic compounds, the short-acting ipratropium, and the long-acting tiotropium in its dry powder formulation, as well as its newer soft mist inhaler delivery device. EXPERT OPINION Pooled analyses and meta-analyses of randomized controlled trials (RCTs) of tiotropium in both its dry powder and soft mist formulations, as well as some observational studies, have implicated this agent as increasing the risk of nonfatal and fatal cardiovascular events. However, the most robust evidence based on large-scale randomized controlled trials (RCTs) of relatively long duration specifically designed to evaluate the cardiovascular safety of tiotropium have not confirmed these safety concerns. Because of the relatively limited amount of safety data for the newer long-acting muscarinic antagonists compared to the far more extensive experience with tiotropium, it will be important to accumulate additional safety information from post-marketing pharmacovigilance for these newer agents.
Collapse
Affiliation(s)
- D P Tashkin
- a Professor of Medicine, University of California-Los Angeles - Medicine, David Geffen School of Medicine at UCLA , 10833 Le Conte Ave, Los Angeles, California 90095, USA +1 31 08 25 31 63 ; +1 31 02 06 50 88 ;
| |
Collapse
|