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Requena G, Czira A, Banks V, Wood R, Tritton T, Castillo CM, Yeap J, Wild R, Compton C, Rothnie KJ, Herth F, Quint JK, Ismaila AS. Comparison of Rescue Medication Prescriptions in Patients with Chronic Obstructive Pulmonary Disease Receiving Umeclidinium/Vilanterol versus Tiotropium Bromide/Olodaterol in Routine Clinical Practice in England. Int J Chron Obstruct Pulmon Dis 2023; 18:1431-1444. [PMID: 37465818 PMCID: PMC10351530 DOI: 10.2147/copd.s411437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/03/2023] [Indexed: 07/20/2023] Open
Abstract
Purpose Routinely collected healthcare data on the comparative effectiveness of the long-acting muscarinic antagonist/long-acting β2-agonist combination umeclidinium/vilanterol (UMEC/VI) versus tiotropium bromide/olodaterol (TIO/OLO) for chronic obstructive pulmonary disease (COPD) is limited. This study compared rescue medication prescriptions in patients with COPD in England receiving UMEC/VI versus TIO/OLO. Patients and Methods This retrospective cohort study used primary care data from the Clinical Practice Research Datalink Aurum database linked with secondary care administrative data from Hospital Episode Statistics. Patients with a COPD diagnosis at age ≥35 years were included (indexed) following initiation of single-inhaler UMEC/VI or TIO/OLO between July 1, 2015, and September 30, 2019. Outcomes included the number of rescue medication prescriptions at 12-months (primary), and at 6-, 18- and 24-months (secondary), adherence at 6-, 12-, 18- and 24-months post-index, defined as proportion of days covered ≥80% (secondary), and time-to-initiation of triple therapy (exploratory). Inverse probability of treatment weighting (IPTW) was used to balance potential confounding baseline characteristics. Superiority of UMEC/VI versus TIO/OLO for the primary outcome of rescue medication prescriptions was assessed using an intention-to-treat analysis with a p-value < 0.05. Results In total, 8603 patients were eligible (UMEC/VI: n = 6536; TIO/OLO: n = 2067). Following IPTW, covariates were well balanced across groups. Patients initiating UMEC/VI had statistically significantly fewer (mean [standard deviation]; p-value) rescue medication prescriptions versus TIO/OLO in both the unweighted (4.84 [4.78] vs 5.68 [5.00]; p < 0.001) and weighted comparison (4.91 [4.81] vs 5.48 [5.02]; p = 0.0032) at 12 months; consistent results were seen at all timepoints. Adherence was numerically higher for TIO/OLO versus UMEC/VI at all timepoints. Time-to-triple therapy was similar between treatment groups. Conclusion UMEC/VI was superior to TIO/OLO in reducing rescue medication prescriptions at 12 months after treatment initiation in a primary care cohort in England, potentially suggesting improvements in symptom control with UMEC/VI compared with TIO/OLO.
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Affiliation(s)
- Gema Requena
- GSK, R&D Global Medical, Brentford, Middlesex, UK
| | | | - Victoria Banks
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Robert Wood
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Theo Tritton
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | | | - Jie Yeap
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Rosie Wild
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | | | | | - Felix Herth
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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2
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Janson C, Wiklund F, Telg G, Stratelis G, Sandelowsky H. High use of short-acting β 2-agonists in COPD is associated with an increased risk of exacerbations and mortality. ERJ Open Res 2023; 9:00722-2022. [PMID: 37342089 PMCID: PMC10277875 DOI: 10.1183/23120541.00722-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/23/2023] [Indexed: 06/22/2023] Open
Abstract
Background Short-acting β2-agonist (SABA) overuse has been associated with an increased risk of exacerbations in asthma; however, less is known about SABA use in COPD. Our aim was to describe SABA use and investigate potential associations between high SABA use and the risk of future exacerbations and mortality in COPD. Methods This observational study identified COPD patients in primary care medical records in Sweden. Data were linked to the National Patient Registry, the Prescribed Drug Registry and the Cause of Death Registry. The index date was 12 months after the date of COPD diagnosis. During a 12-month prior to index baseline period, information on SABA use was collected. Patients were followed with respect to exacerbations and mortality for 12 months post index. Results Of the 19 794 COPD patients included (mean age 69.1 years, 53.3% females), 15.5% and 7.0% had collected ≥3 or ≥6 SABA canisters during the baseline period, respectively. A higher level of SABA use (≥6 canisters) was independently associated with a higher risk of both moderate and severe exacerbations (hazard ratio (HR) 1.28 (95% CI 1.17‒1.40) and 1.76 (95% CI 1.50‒2.06), respectively) during follow-up. In total, 673 (3.4%) patients died during the 12-month follow-up period. An independent association was found between high SABA use and overall mortality (HR 1.60, 95% CI 1.07‒2.39). This association, however, was not found in patients using inhaled corticosteroids as maintenance treatment. Conclusion In COPD patients in Sweden, high SABA use is relatively common and associated with a higher risk of exacerbations and all-cause mortality.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | | | - Georgios Stratelis
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
- AstraZeneca Nordic, Stockholm, Sweden
| | - Hanna Sandelowsky
- Department of Medicine, Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, , Stockholm, Sweden
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3
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Kerwin EM, Jones PW, Bjermer LH, Maltais F, Boucot IH, Naya IP, Lipson DA, Compton C, Tombs L, Vogelmeier CF. How can the findings of the EMAX trial on long-acting bronchodilation in chronic obstructive pulmonary disease be applied in the primary care setting? Chron Respir Dis 2023; 20:14799731231202257. [PMID: 37800633 PMCID: PMC10903204 DOI: 10.1177/14799731231202257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 08/21/2023] [Indexed: 10/07/2023] Open
Abstract
This review addresses outstanding questions regarding initial pharmacological management of chronic obstructive pulmonary disease (COPD). Optimizing initial treatment improves clinical outcomes in symptomatic patients, including those with low exacerbation risk. Long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) dual therapy improves lung function versus LAMA or LABA monotherapy, although other treatment benefits have been less consistently observed. The benefits of dual bronchodilation in symptomatic patients with COPD at low exacerbation risk, and its duration of efficacy and cost effectiveness in this population, are not yet fully established. Questions remain on the impact of baseline symptom severity, prior treatment, degree of reversibility to bronchodilators, and smoking status on responses to dual bronchodilator treatment. Using evidence from EMAX (NCT03034915), a 6-month trial comparing the LAMA/LABA combination umeclidinium/vilanterol with umeclidinium and salmeterol monotherapy in symptomatic patients with COPD at low exacerbation risk who were inhaled corticosteroid-naïve, we describe how these findings can be applied in primary care.
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Affiliation(s)
- Edward M Kerwin
- Clinical Trials Department, Altitude Clinical Consulting and Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | - Leif H Bjermer
- Department of Clinical Sciences, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - François Maltais
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | | | | | - David A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Stockley Park West, Uxbridge, UK
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
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Czira A, Requena G, Banks V, Wood R, Tritton T, Castillo CM, Yeap J, Wild R, Compton C, Rothnie KJ, Herth F, Quint JK, Ismaila AS. Comparative Effectiveness of Umeclidinium/Vilanterol versus Inhaled Corticosteroid/Long-Acting β 2-Agonist in Patients with Chronic Obstructive Pulmonary Disease in a Primary Care Setting in England. Int J Chron Obstruct Pulmon Dis 2023; 18:643-659. [PMID: 37155496 PMCID: PMC10122847 DOI: 10.2147/copd.s405498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/06/2023] [Indexed: 05/10/2023] Open
Abstract
Purpose To compare adherence to once-daily umeclidinium/vilanterol (UMEC/VI), a long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA), and twice-daily inhaled corticosteroids (ICS)/LABA single-inhaler dual therapy in patients with chronic obstructive pulmonary disease (COPD) in a primary care cohort in England. Patients and Methods Active comparator, new-user, retrospective cohort study using CPRD-Aurum primary care data and linked Hospital Episode Statistics secondary care administrative data. Patients without exacerbations in the previous year were indexed on first/earliest prescription date of once-daily UMEC/VI or twice-daily ICS/LABA as initial maintenance therapy between July 2014-September 2019. Primary outcome: medication adherence at 12 months post-index, defined as proportion of days covered (PDC) ≥80%. PDC represented proportion of time over the treatment duration that the patient was theoretically in possession of the medication. Secondary outcomes: adherence at 6, 18, and 24 months post-index, time-to-triple therapy, time-to-first on-treatment COPD exacerbation, COPD-related and all-cause healthcare resource utilization (HCRU), and direct health-care costs. A propensity score was generated and inverse probability of treatment weighting (IPTW) was used to balance potential confounders. Superiority was defined as >0% difference between treatment groups. Results In total, 6815 eligible patients were included (UMEC/VI:1623; ICS/LABA:5192). At 12 months post-index, weighted odds of a patient being adherent were significantly greater with UMEC/VI versus ICS/LABA (odds ratio [95% CI]: 1.71 [1.09, 2.66]; p=0.0185), demonstrating superiority of UMEC/VI. Patients taking UMEC/VI were statistically significantly more adherent than those taking ICS/LABA at 6, 18, and 24 months post-index (p<0.05). Differences in time-to-triple therapy, time-to-moderate COPD exacerbations, HCRU, and direct medical costs were not statistically significant between treatments after IPTW was applied. Conclusion At 12 months post-treatment initiation, once-daily UMEC/VI was superior to twice-daily ICS/LABA in medication adherence among patients with COPD without exacerbations in the previous year, newly initiating dual maintenance therapy in England. The finding was consistent at 6, 18, and 24 months.
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Affiliation(s)
- Alexandrosz Czira
- R&D Global Medical, GSK, Brentford, Middlesex, UK
- Correspondence: Alexandrosz Czira, Value Evidence and Outcomes, R&D Global Medical, GSK, Brentford, Middlesex, UK, Tel +44 7788 351610, Email
| | - Gema Requena
- R&D Global Medical, GSK, Brentford, Middlesex, UK
| | - Victoria Banks
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Robert Wood
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Theo Tritton
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | | | - Jie Yeap
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Rosie Wild
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | | | | | - Felix Herth
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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5
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Ohnishi H, Eitoku M, Yokoyama A. A systematic review and integrated analysis of biologics that target Type 2 inflammation to treat COPD with increased peripheral blood eosinophils. Heliyon 2022; 8:e09736. [PMID: 35756113 PMCID: PMC9218150 DOI: 10.1016/j.heliyon.2022.e09736] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Background and aims Biologics that target Type 2 inflammation are effective in reducing exacerbations of severe asthma. We conducted a systematic review and integrated analysis of the efficacy and safety of these biologics in chronic obstructive pulmonary disease (COPD) patients with increased peripheral blood eosinophils. Methods Clinical trials of biologics that target Type 2 inflammation in COPD were found using PubMed, the Cochrane Library, and ClinicalTrials.gov. We analyzed the clinical efficacy of anti-IL-5-targeted therapy at approved (benralizumab 30 mg, mepolizumab 100 mg, for severe asthma) and high (benralizumab 100 mg, mepolizumab 300 mg) doses. Results Approved benralizumab and mepolizumab doses tended to reduce moderate-to-severe exacerbations by 9% [risk ratio (RR) 0.91, 95% confidence interval (CI) [0.83, 1.00], p = 0.05], but did not reduce exacerbations requiring emergency department visits or hospitalization. High-dose benralizumab and mepolizumab reduced moderate-to-severe exacerbations by 12% (RR = 0.88, 95% CI [0.80, 0.98], p = 0.02) and exacerbations requiring emergency department visits or hospitalization by 33% (RR = 0.67, 95% CI [0.53, 0.84], p = 0.0005). Neither dose improved St. George's Respiratory Questionnaire or COPD Assessment Test scores. The safety of benralizumab and mepolizumab was comparable to placebo. Conclusions Benralizumab and mepolizumab have limited efficacy in reducing moderate-to-severe exacerbations in COPD patients with increased peripheral blood eosinophils and requires at least high doses. This integrated analysis shows limited efficacy of anti-IL-5 therapy in COPD. High doses of anti-IL-5 therapy are required to reduce moderate-to-severe exacerbations.
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Affiliation(s)
- Hiroshi Ohnishi
- Department of Respiratory Medicine and Allergology, Oko-cho, Kohasu, Nankoku, Kochi, 780-8505, Japan
| | - Masamitsu Eitoku
- Department of Environmental Medicine, Kochi Medical School, Kochi University, Oko-cho, Kohasu, Nankoku, Kochi, 780-8505, Japan
| | - Akihito Yokoyama
- Department of Respiratory Medicine and Allergology, Oko-cho, Kohasu, Nankoku, Kochi, 780-8505, Japan
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6
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Grøvle L, Hasvik E, Haugen AJ. Impact of rescue medication in placebo-controlled trials of pharmacotherapy for neuropathic pain and low back pain. Pain 2022; 163:e417-e425. [PMID: 34407031 DOI: 10.1097/j.pain.0000000000002380] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Rescue medication (RM) consumption is commonly used as a secondary outcome in placebo-controlled trials of chronic pain, but its validity has yet to be established. If participants randomized to placebo take more RM than those randomized to an active drug, the difference in pain between the 2 groups may be reduced, potentially masking effects of the active drug. This study assessed proportional RM consumption in the placebo and active groups according to results of 42 randomized controlled trials of neuropathic pain (NeP), and 29 trials of low back pain, which were included in 2 systematic reviews and meta-analyses. Trial results were assessed based on effect size, statistical significance, and whether the drug was recommended as first-line treatment by the systematic reviews. In trials indicating effect of the investigational drug, RM consumption was generally higher in the placebo groups than in the active groups. In trials reporting a small or a medium effect size of the investigational drug, subjects receiving placebo consumed 17% to 30% more RM than subjects receiving active drug, potentially leading to underestimation of the effects of the investigational drugs. Few trials reported a large effect size. Differences in RM consumption between participants receiving placebo and those receiving active drug were seldom taken in account by the individual trials and not at all by the systemic reviews when making treatment recommendations for NeP or low back pain. Elaboration on analytical methods to assess treatment effects in chronic pain trials using RM is warranted.
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Affiliation(s)
- Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Grålum, Norway
| | - Eivind Hasvik
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Grålum, Norway
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Amegadzie JE, Gamble JM, Farrell J, Gao Z. Risk of all-cause mortality or hospitalization for pneumonia associated with inhaled β2-agonists in patients with asthma, COPD or asthma-COPD overlap. Respir Res 2022; 23:364. [PMID: 36539784 PMCID: PMC9764507 DOI: 10.1186/s12931-022-02295-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
β2-agonists provide necessary bronchodilatory action, are recommended by existing clinical practice guidelines and are widely prescribed for patients with these conditions. We examined the risk of all-cause mortality and hospitalization for pneumonia associated with long-or short-acting β2-agonists (LABA or SABA) or ICS (inhaled corticosteroids)/LABA use. In a nested case-control of 185,407 patients, we found no association between β2-agonist use and the risk of pneumonia in patients with asthma, COPD, or asthma-COPD overlap. In contrast, new SABA [HR 1.82 (95% CI 1.04-3.20)] or LABA [HR 2.77 (95% CI 1.22-6.31)] use was associated with an increased risk of all-cause mortality compared to ICS use in COPD patients.
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Affiliation(s)
- Joseph Emil Amegadzie
- grid.25055.370000 0000 9130 6822Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John’s, NL A1B 3V6 Canada
| | - John-Michael Gamble
- grid.46078.3d0000 0000 8644 1405Faculty of Science, School of Pharmacy, University of Waterloo, Waterloo, ON Canada
| | - Jamie Farrell
- grid.25055.370000 0000 9130 6822Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John’s, NL A1B 3V6 Canada
| | - Zhiwei Gao
- grid.25055.370000 0000 9130 6822Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John’s, NL A1B 3V6 Canada
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8
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Bjermer L, Boucot IH, Maltais F, Kerwin EM, Naya IP, Tombs L, Jones PW, Compton C, Lipson DA, Vogelmeier CF. Dual Bronchodilator Therapy as First-Line Treatment in Maintenance-Naïve Patients with Symptomatic COPD: A Pre-Specified Analysis of the EMAX Trial. Int J Chron Obstruct Pulmon Dis 2021; 16:1939-1956. [PMID: 34234425 PMCID: PMC8254100 DOI: 10.2147/copd.s291751] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Limited prospective evidence is available to guide selection of first-line maintenance therapy in patients with COPD. This pre-specified analysis of the EMAX trial explored the efficacy and safety of dual- versus mono-bronchodilator therapy in maintenance-naïve and maintenance-treated patients. Methods The 24-week EMAX trial evaluated lung function, symptoms (including rescue medication use), exacerbations, and safety with umeclidinium/vilanterol, umeclidinium, and salmeterol in symptomatic patients at low exacerbation risk who were not receiving inhaled corticosteroids. Maintenance-naïve and maintenance-treated subgroups were defined by maintenance bronchodilator use 30 days before screening. Results The analysis included 749 (31%) maintenance-naïve and 1676 (69%) maintenance-treated patients. For both subgroups, improvements from baseline in trough FEV1 at Week 24 (primary endpoint) were greater with umeclidinium/vilanterol versus umeclidinium (mean difference [95% CI]; maintenance-naïve: 44 mL [1, 87]; maintenance-treated: 77 mL [50, 104]), and salmeterol (maintenance-naïve: 128 mL [85, 171]; maintenance-treated: 145 mL [118, 172]), and in rescue medication inhalations/day over 24 weeks versus umeclidinium (maintenance-naïve: −0.44 [−0.73, −0.16]; maintenance-treated: −0.28 [−0.45, −0.12]) and salmeterol (maintenance-naïve: −0.37 [−0.66, −0.09]; maintenance-treated: −0.25 [−0.41, −0.08]). In maintenance-naïve patients, umeclidinium/vilanterol numerically improved scores at Week 24 for Transition Dyspnea Index versus umeclidinium (0.37 [−0.21, 0.96]) and versus salmeterol (0.47 [−0.10, 1.05]) and Evaluating Respiratory Symptoms–COPD versus umeclidinium (−0.26 [−1.04, 0.53]) and versus salmeterol (−0.58 [−1.36, 0.20]), with similar improvements seen in maintenance-treated patients. All treatments were well tolerated across both subgroups. Conclusion Similar to maintenance-treated patients, maintenance-naïve patients receiving umeclidinium/vilanterol showed greater improvements in lung function and symptoms compared with patients receiving umeclidinium or salmeterol. These findings provide support for the consideration of dual bronchodilator treatment in symptomatic maintenance-naïve patients with COPD.
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Affiliation(s)
- Leif Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | | | - François Maltais
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Ian P Naya
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Lee Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Paul W Jones
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Chris Compton
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - David A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
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Kerwin EM, Boucot IH, Vogelmeier CF, Maltais F, Naya IP, Tombs L, Jones PW, Lipson DA, Keeley T, Bjermer L. Early and sustained symptom improvement with umeclidinium/vilanterol versus monotherapy in COPD: a post hoc analysis of the EMAX randomised controlled trial. Ther Adv Respir Dis 2021; 14:1753466620926949. [PMID: 32462979 PMCID: PMC7278094 DOI: 10.1177/1753466620926949] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: In chronic obstructive pulmonary disease (COPD), both the time needed for
patients to gain symptom improvement with long-acting bronchodilator therapy
and whether an early response is predictive of a sustained response is
unknown. This study aimed to investigate how quickly meaningful symptom
responses are seen in patients with COPD with bronchodilator therapy and
whether these responses are sustained. Methods: Early MAXimisation of bronchodilation for improving COPD stability (EMAX) was
a 24-week, double-blind, double-dummy, parallel-group trial that randomised
patients to umeclidinium/vilanterol (UMEC/VI), umeclidinium or salmeterol.
Daily Evaluating Respiratory Symptoms in COPD (E-RS:COPD) score and rescue
salbutamol use were captured via an electronic diary and
analysed initially in 4-weekly periods. Post hoc analyses
assessed change from baseline in daily E-RS:COPD score and rescue medication
use weekly (Weeks 1–8), and association between E-RS:COPD responder status
at Weeks 1–4 and later time points. Results: In the intent-to-treat population (n = 2425), reductions
from baseline in E-RS:COPD scores and rescue medication use were apparent
from Day 2 with all treatments. Treatment differences for UMEC/VI
versus either monotherapy plateaued by Week 4–8 and
were sustained at Weeks 21–24; improvements were consistently greater with
UMEC/VI. For all treatments, most patients (60–85%) retained their Weeks 1–4
E-RS:COPD responder/non-responder status at Weeks 21−24. Among patients
receiving UMEC/VI who were E-RS:COPD responders at Weeks 1–4, 70% were
responders at Weeks 21–24. Conclusion: Patients with symptomatic COPD had greater potential for early symptom
improvements with UMEC/VI versus either monotherapy. This
benefit was generally maintained for 24 weeks. Early monitoring of treatment
response can provide clinicians with an early indication of a patient’s
likely longer-term response to prescribed bronchodilator treatment and will
facilitate appropriate early adjustments in care. Clinical Trial Registration: NCT03034915, 2016-002513-22 (EudraCT Number). The reviews of this paper are available via the supplemental
material section.
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Affiliation(s)
- Edward M Kerwin
- Crisor LLC, Clinical Research Institute, 3860 Crater Lake Ave., Medford, OR 97504, USA
| | | | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Germany
| | - Francois Maltais
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada
| | - Ian P Naya
- GSK, Brentford, Middlesex, UK.,RAMAX Ltd, Bramhall, Cheshire, UK
| | - Lee Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | | | - David A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tom Keeley
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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Valipour A, Avdeev S, Barczyk A, Bayer V, Fridlender Z, Georgieva M, Kudela O, Medvedchikov A, Miron R, Sanzharovskaya M, Šileikienė V, Šorli J, Spielmanns M, Szalai Z. Therapeutic Success of Tiotropium/Olodaterol, Measured Using the Clinical COPD Questionnaire (CCQ), in Routine Clinical Practice: A Multinational Non-Interventional Study. Int J Chron Obstruct Pulmon Dis 2021; 16:615-628. [PMID: 33731991 PMCID: PMC7956863 DOI: 10.2147/copd.s291920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/07/2021] [Indexed: 01/16/2023] Open
Abstract
Background The Clinical COPD Questionnaire (CCQ) is a simple patient-reported tool to measure clinical control of chronic obstructive pulmonary disease (COPD). Objective This open-label, single-arm, non-interventional study (NCT03663569) investigated changes in CCQ score during treatment with tiotropium/olodaterol in clinical practice. Methods Data were included from consenting COPD patients, enrolled in Bulgaria, Czech Republic, Hungary, Israel, Lithuania, Poland, Romania, Russia, Slovenia, Switzerland and Ukraine, who were receiving a new prescription for tiotropium/olodaterol according to the treating physician in a real-world environment. The primary endpoint was the occurrence of therapeutic success, defined as a 0.4-point decrease in CCQ score after treatment with tiotropium/olodaterol for approximately 6 weeks. Results Overall, 4819 patients were treated; baseline and Week 6 CCQ scores were available for 4700 patients, mostly classified as Global Initiative for Chronic Obstructive Lung Disease (GOLD) B (51.6%) or D (42.7%). After 6 weeks’ treatment, 81.4% (95% confidence interval [95% CI] 80.24–82.49) of patients achieved therapeutic success; mean improvement in overall CCQ score was 1.02 points (95% CI 1.00–1.05). Improved CCQ score was seen in 92.2% of patients (95% CI 91.43–92.98), 2.5% had no change and 5.3% showed a worsening. When stratified by prior treatment, the greatest benefit was seen in treatment-naïve patients, with 85.7% achieving therapeutic success, compared with 79.5% of those pretreated with long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) and 74.2% of those pretreated with LABA or long-acting muscarinic antagonist (LAMA) monotherapy. Overall, rescue medication decreased by 1.25 puffs/day (95% CI 1.19–1.31) versus baseline. In total, 29 patients (0.6%) reported drug-related adverse events and 7 patients reported serious adverse events (0.15%). Conclusion In 4700 COPD patients, 6 weeks’ treatment with tiotropium/olodaterol, as initial treatment or follow-up to LAMA or LABA monotherapy or LABA/ICS, improved CCQ and decreased rescue medication use. The adverse event profile was consistent with the known safety profile of tiotropium/olodaterol.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna Health Care Group, Klinik Floridsdorf, Vienna, Austria
| | - Sergey Avdeev
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Adam Barczyk
- Wydział Nauk Medycznych Śląskiego Uniwersytetu Medycznego, Katowice, Poland
| | - Valentina Bayer
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Zvi Fridlender
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Ondřej Kudela
- Department of Pneumology, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | | | - Ramona Miron
- Clinical Pneumophtysiology Hospital Iasi, Iasi, Romania
| | | | - Virginija Šileikienė
- Faculty of Medicine, Clinic of Chest Diseases, Immunology and Allergology, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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11
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Maltais F, Naya IP, Vogelmeier CF, Boucot IH, Jones PW, Bjermer L, Tombs L, Compton C, Lipson DA, Kerwin EM. Salbutamol use in relation to maintenance bronchodilator efficacy in COPD: a prospective subgroup analysis of the EMAX trial. Respir Res 2020; 21:280. [PMID: 33092591 PMCID: PMC7579818 DOI: 10.1186/s12931-020-01451-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/09/2020] [Indexed: 11/12/2022] Open
Abstract
Background Short-acting β2-agonist (SABA) bronchodilators help alleviate symptoms in chronic obstructive pulmonary disease (COPD) and may be a useful marker of symptom severity. This analysis investigated whether SABA use impacts treatment differences between maintenance dual- and mono-bronchodilators in patients with COPD. Methods The Early MAXimisation of bronchodilation for improving COPD stability (EMAX) trial randomised symptomatic patients with low exacerbation risk not receiving inhaled corticosteroids 1:1:1 to once-daily umeclidinium/vilanterol 62.5/25 μg, once-daily umeclidinium 62.5 μg or twice-daily salmeterol 50 μg for 24 weeks. Pre-specified subgroup analyses stratified patients by median baseline SABA use (low, < 1.5 puffs/day; high, ≥1.5 puffs/day) to examine change from baseline in trough forced expiratory volume in 1 s (FEV1), change in symptoms (Transition Dyspnoea Index [TDI], Evaluating Respiratory Symptoms-COPD [E-RS]), daily SABA use and exacerbation risk. A post hoc analysis used fractional polynomial modelling with continuous transformations of baseline SABA use covariates. Results At baseline, patients in the high SABA use subgroup (mean: 3.91 puffs/day, n = 1212) had more severe airflow limitation, were more symptomatic and had worse health status versus patients in the low SABA use subgroup (0.39 puffs/day, n = 1206). Patients treated with umeclidinium/vilanterol versus umeclidinium demonstrated statistically significant improvements in trough FEV1 at Week 24 in both SABA subgroups (59–74 mL; p < 0.001); however, only low SABA users demonstrated significant improvements in TDI (high: 0.27 [p = 0.241]; low: 0.49 [p = 0.025]) and E-RS (high: 0.48 [p = 0.138]; low: 0.60 [p = 0.034]) scores. By contrast, significant reductions in mean SABA puffs/day with umeclidinium/vilanterol versus umeclidinium were observed only in high SABA users (high: − 0.56 [p < 0.001]; low: − 0.10 [p = 0.132]). Similar findings were observed when comparing umeclidinium/vilanterol and salmeterol. Fractional polynomial modelling showed baseline SABA use ≥4 puffs/day resulted in smaller incremental symptom improvements with umeclidinium/vilanterol versus umeclidinium compared with baseline SABA use < 4 puffs/day. Conclusions In high SABA users, there may be a smaller difference in treatment response between dual- and mono-bronchodilator therapy; the reasons for this require further investigation. SABA use may be a confounding factor in bronchodilator trials and in high SABA users; changes in SABA use may be considered a robust symptom outcome. Funding GlaxoSmithKline (study number 201749 [NCT03034915]).
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Affiliation(s)
- F Maltais
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada.
| | - I P Naya
- GSK, Brentford, Middlesex, UK.,RAMAX Ltd, Bramhall, Cheshire, UK
| | - C F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
| | | | | | - L Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - L Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | | | - D A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
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12
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Moretz C, Cole AL, Mu G, Wu B, Guisinger A, Liu Y, Hahn B, Baylis L. Evaluation of Medication Adherence and Rescue Medication Use in Non-Exacerbating Patients with COPD Receiving Umeclidinium/Vilanterol or Budesonide/Formoterol as Initial Maintenance Therapy. Int J Chron Obstruct Pulmon Dis 2020; 15:2207-2215. [PMID: 32982213 PMCID: PMC7502389 DOI: 10.2147/copd.s259850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022] Open
Abstract
Background Adherence to inhaled maintenance therapy is critical to managing chronic obstructive pulmonary disease (COPD), while increasing rescue medication usage may indicate worsening symptoms. This study evaluated adherence and rescue medication use in patients with COPD without a history of exacerbation who initiated combination therapy with budesonide/formoterol (B/F) or umeclidinium/vilanterol (UMEC/VI). Methods Retrospective observational study of commercially insured and Medicare Advantage with Part D enrollees who initiated UMEC/VI or B/F between January 1, 2014 and December 31, 2017 (earliest fill defined as index date). Eligibility criteria included age ≥40 years, 12 months continuous enrollment pre- and post-index, ≥1 pre-index COPD diagnosis, no pre-index asthma diagnosis, COPD-related exacerbations, or medication fills containing inhaled corticosteroids, long-acting β2-agonists, or long-acting muscarinic antagonists. Inverse probability of treatment weighting (IPTW) was used to balance treatment groups on potential confounders. Medication adherence (primary endpoint) was evaluated by the proportion of days covered (PDC). Rescue medication use (secondary endpoint) was standardized to canister equivalents (1 metered dose inhaler [200 puffs] or ~100 nebulized doses of short-acting β2-agonist- and/or short-acting muscarinic agonist-containing medication). Results After IPTW, covariates were balanced between cohorts (UMEC/VI: N=4082; B/F: N=9529). UMEC/VI initiators had a significantly greater mean PDC (UMEC/VI: 0.47 [0.33]; B/F: 0.38 [0.30]; P<0.001) and significantly higher rates of adherence (PDC≥0.80) than B/F initiators (UMEC/VI: n=1004 [25%], B/F: n=1391 [15%]; relative risk: 1.68, 95% CI: 1.57, 1.81; P<0.001). In the year following initiation, UMEC/VI initiators filled significantly fewer rescue medication canister equivalents than B/F initiators (predicted mean [95% CI]: 1.78 [1.69, 1.88] vs 2.15 [2.08, 2.23]; mean difference [95% CI]: −0.37 [−0.50, −0.24]; P<0.001), corresponding to 17% less (estimated) rescue medication use (incidence rate ratio [95% CI]: 0.83 [0.78, 0.88]). Conclusion Among non-exacerbating patients with COPD initiating dual therapy, UMEC/VI demonstrated improved adherence and reduced rescue medication use compared with B/F.
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Affiliation(s)
- Chad Moretz
- US Value Evidence & Outcomes, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
| | - Ashley L Cole
- VEO Data, Methods, and Analytics, GlaxoSmithKline, Collegeville, PA, USA
| | - George Mu
- VEO Data, Methods, and Analytics, GlaxoSmithKline, Collegeville, PA, USA
| | - Benjamin Wu
- US Value Evidence & Outcomes, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
| | - Amy Guisinger
- US Value Evidence & Outcomes, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
| | - Yunhao Liu
- VEO Data, Methods, and Analytics, GlaxoSmithKline, Collegeville, PA, USA
| | - Beth Hahn
- US Value Evidence & Outcomes, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
| | - Lee Baylis
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, Durham, NC, USA
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13
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Donohue JF, Ozol-Godfrey A, Goodin T, Sanjar S. The Effect of Baseline Rescue Medication Use on Efficacy and Safety of Nebulized Glycopyrrolate Treatment in Patients with COPD from the GOLDEN 3 and 4 Studies. Int J Chron Obstruct Pulmon Dis 2020; 15:745-754. [PMID: 32341641 PMCID: PMC7166066 DOI: 10.2147/copd.s242767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/30/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Rescue medication use is common in chronic obstructive pulmonary disease (COPD) patients and tends to increase with symptoms and disease severity. An analysis of baseline rescue medication use was conducted to inform on patient phenotypes and subsequent effects on lung function, symptoms, and safety following 12 weeks of nebulized glycopyrrolate (GLY) 25 µg twice daily or placebo in patients with moderate-to-very-severe COPD. Patients and Methods Pooled data from the 12-week, placebo-controlled GOLDEN 3 and 4 studies (n=781) were used to assign patients into quarters based on baseline rescue medication use (ie, average puffs-per-day) during the run-in period. Placebo-adjusted trough forced expiratory volume in 1 second (FEV1), St. George's Respiratory Questionnaire (SGRQ) total score and EXAcerbations of COPD Tool-Respiratory Symptoms (EXACT-RS) total score data were reported; safety was evaluated by reviewing the incidence of adverse events (AEs) and serious AEs (SAEs). Results Baseline rescue medication use was a proxy for disease severity, evidenced by decreased lung function, increased health status scores, symptom scores and use of background long-acting β2-agonists and inhaled corticosteroids across quarters and treatment groups. Treatment with GLY led to greater improvements from baseline in trough FEV1, SGRQ and EXACT-RS scores compared with placebo in all rescue medication use quarters. Additionally, the SGRQ and EXACT-RS exhibited greater improvement with increased baseline rescue medication use with GLY treatment. In the Q4 patients, SGRQ (≥4-unit reduction) or EXACT-RS (≥2-unit reduction) responders were significantly greater with GLY compared with placebo. AE and SAE incidences were similar across quartiles. Conclusion These results suggest that baseline rescue medication use assessments may be useful in the management of COPD. Treatment with nebulized GLY improved lung function and symptom scores, regardless of baseline rescue medication use. These results support the use of nebulized GLY for the treatment of COPD, independent of baseline rescue medication use.
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Affiliation(s)
- James F Donohue
- Department of Pulmonary Diseases and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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14
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Zheng J, Xu JF, Jenkins M, Assam PN, Wang L, Lipworth BJ. Glycopyrrolate/formoterol fumarate metered dose inhaler for maintenance-naïve patients with chronic obstructive pulmonary disease: a post-hoc analysis of the randomized PINNACLE trials. Respir Res 2020; 21:69. [PMID: 32164675 PMCID: PMC7068860 DOI: 10.1186/s12931-020-1332-3] [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] [Received: 12/22/2019] [Accepted: 03/02/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Glycopyrrolate (GP)/formoterol fumarate (FF; GFF) metered dose inhaler is a fixed-dose combination dual bronchodilator for patients with chronic obstructive pulmonary disease (COPD); however, whether the efficacy in patients without current maintenance treatment is consistent with currently maintenance-treated patients is unclear. METHODS Data from patients who were not maintenance-treated at screening (NMT) (n = 1943) and patients who were maintenance-treated at screening (MT) patients (n = 3040) receiving GFF, FF, GP, or placebo were pooled from the Phase III PINNACLE studies (NCT01854645, NCT01854658, NCT02343458) for post-hoc analysis. MT patients had received long-acting bronchodilators and/or inhaled corticosteroids in the 30 days prior to screening, and/or prior to randomization. NMT patients had received short-acting bronchodilators or no treatment. Outcomes included forced expiratory volume over 1 s (FEV1), clinically important deterioration (CID), rescue medication use, and safety. RESULTS GFF provided significant lung function improvements at Week 24 versus placebo, GP, and FF for NMT patients, with pre-dose trough FEV1 treatment differences of 152 (117-188) mL, 73 (45-100) mL, and 56 (29-84) mL, respectively (least squares mean change from baseline versus comparators [95% CI]; all P < 0.0001). GFF reduced the risk of CID by 17-43% in NMT (P ≤ 0.0157) and 18-52% (P ≤ 0.0012) in MT patients compared with monotherapy and placebo, and reduced rescue medication use by 1.5 puffs/day over 24 weeks for both cohorts. Safety profiles for all cohorts were consistent with each other and the parent studies. CONCLUSIONS NMT patients achieved better lung function with GFF versus monotherapy and placebo, without increased safety risk. Dual bronchodilator therapy may offer better outcomes than monotherapy for COPD patients when administered as first-line treatment.
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Affiliation(s)
- Jinping Zheng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Martin Jenkins
- Global Medicines Development, AstraZeneca, Central Cambridge, UK
| | | | - Lijiao Wang
- Medical Affairs, AstraZeneca, Shanghai, China
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Dundee, DD1 9SY, Scotland, UK.
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15
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Naya I, Tombs L, Lipson DA, Boucot I, Compton C. Impact of prior and concurrent medication on exacerbation risk with long-acting bronchodilators in chronic obstructive pulmonary disease: a post hoc analysis. Respir Res 2019; 20:60. [PMID: 30914064 PMCID: PMC6434823 DOI: 10.1186/s12931-019-1027-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/18/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Symptomatic patients with chronic obstructive pulmonary disease (COPD) and low exacerbation risk still have disease instability, which can be improved with better bronchodilation. We evaluated two long-acting bronchodilators individually and in combination on reducing exacerbation risk and the potential impact of concurrent medication in these patients. METHODS Integrated post hoc intent-to-treat (ITT) analysis of data from two large 24-week, randomized placebo (PBO)-controlled trials (NCT01313637, NCT01313650). Symptomatic patients with moderate-to-very-severe COPD with/without an exacerbation history were randomized (2:3:3:3) to once-daily: PBO, umeclidinium/vilanterol (UMEC/VI 62.5/25 μg [NCT01313650] or 125/25 μg [NCT01313637]), UMEC (62.5 [NCT01313650] or 125 μg [NCT01313637]) or VI (25 μg) via the ELLIPTA inhaler. Medication subgroups were segmented by treatment status at screening: a) maintenance-naïve or on maintenance medications, b) inhaled corticosteroid [ICS]-free or ICS-treated, c) low or high albuterol use based on median run-in use (< 3.6 or ≥ 3.6 puffs/day). Time to first moderate/severe exacerbation (Cox proportional hazard model) and change from baseline in trough forced expiratory volume in 1 s (FEV1; mixed model repeated measures) were analyzed. Safety was also assessed. RESULTS Of 3021 patients (ITT population; UMEC/VI: n = 816; UMEC: n = 825; VI: n = 825; PBO: n = 555), 36% had a recent exacerbation history, 33% were maintenance-naïve, 51% were ICS-free. Mean baseline albuterol use was 5.1 puffs/day. In the ITT population, UMEC/VI, UMEC, and VI reduced the risk of a first exacerbation versus PBO by 58, 44, and 39%, respectively (all p < 0.05). UMEC/VI provided significant risk reductions versus PBO in all subgroups. VI had no benefit versus PBO in maintenance-naïve, ICS-free, and low rescue use patients and was significantly less effective than UMEC/VI in these subgroups. UMEC had no significant benefit versus PBO in maintenance-naïve and ICS-free patients. All bronchodilators improved FEV1 versus PBO, and UMEC/VI significantly improved FEV1 versus both monotherapies across all populations studied (p < 0.05). All bronchodilators were similarly well tolerated. CONCLUSIONS Results suggest that UMEC/VI reduces exacerbation risk versus PBO more consistently across medication subgroups than UMEC or VI, particularly in patients with no/low concurrent medication use. Confirmed prospectively, these findings may support first-line use of dual bronchodilation therapy in symptomatic low-risk patients.
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Affiliation(s)
- Ian Naya
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS UK
| | - Lee Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - David A. Lipson
- Respiratory Research and Development, GSK, Collegeville, PA USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Isabelle Boucot
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS UK
| | - Chris Compton
- Global Respiratory Franchise, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS UK
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16
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Derom E, Brusselle GG, Joos GF. The once-daily fixed-dose combination of olodaterol and tiotropium in the management of COPD: current evidence and future prospects. Ther Adv Respir Dis 2019; 13:1753466619843426. [PMID: 31002020 PMCID: PMC6475840 DOI: 10.1177/1753466619843426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/18/2019] [Indexed: 11/17/2022] Open
Abstract
Long-acting bronchodilators are the cornerstone of pharmacologic treatment of chronic obstructive pulmonary disease (COPD). Spiolto® or Stiolto® is a fixed-dose combination (FDC) containing two long-acting bronchodilators, the long-acting muscarinic receptor antagonist tiotropium (TIO) and the long-acting β2-adrenoceptor agonist olodaterol (OLO), formulated in the Respimat® Soft Mist™ inhaler. A total of 13 large, multicentre studies of up to 52 weeks' duration have documented its efficacy in more than 15,000 patients with COPD. TIO/OLO 5/5 µg FDC significantly increases pulmonary function compared with placebo and its respective constituent mono-components TIO 5 µg and OLO 5 µg. TIO/OLO 5/5 µg also results in statistically and clinically significant improvements in patient-reported outcomes, such as dyspnoea, use of rescue medication, and health status. Addition of OLO 5 µg to TIO 5 µg reduces the rate of moderate-to-severe exacerbations by approximately 10%. Compared with placebo and TIO 5 µg, TIO/OLO 5/5 µg significantly improves exercise capacity (e.g. endurance time) and physical activity, the latter increase being reached by a unique combination behavioural modification intervention, dual bronchodilatation and exercise training. Overall, the likelihood for patients to experience a clinically significant benefit is higher with TIO/OLO 5/5 µg than with its constituent mono-components, which usually yield smaller improvements which do not always reach statistical significance, compared with baseline or placebo. This supports the early introduction of TIO/OLO 5/5 µg in the management of patients with symptomatic COPD.
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Affiliation(s)
- Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Ingang 12, Route 1404, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
| | - Guy G. Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Guy F. Joos
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
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17
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Melani AS. Olodaterol for the treatment of chronic obstructive pulmonary disease: a narrative review. Expert Opin Pharmacother 2018; 19:1603-1611. [DOI: 10.1080/14656566.2018.1518431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Andrea S. Melani
- Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte, Azienda Ospedaliera Universitaria Senese, Siena, Italy
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18
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Naya IP, Tombs L, Lipson DA, Compton C. Preventing Clinically Important Deterioration of COPD with Addition of Umeclidinium to Inhaled Corticosteroid/Long-Acting β 2-Agonist Therapy: An Integrated Post Hoc Analysis. Adv Ther 2018; 35:1626-1638. [PMID: 30191464 PMCID: PMC6182634 DOI: 10.1007/s12325-018-0771-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Assessing clinically important measures of disease progression is essential for evaluating therapeutic effects on disease stability in chronic obstructive pulmonary disease (COPD). This analysis assessed whether providing additional bronchodilation with the long-acting muscarinic antagonist umeclidinium (UMEC) to patients treated with inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) therapy would improve disease stability compared with ICS/LABA therapy alone. METHODS This integrated post hoc analysis of four 12-week, randomized, double-blind trials (NCT01772134, NCT01772147, NCT01957163, NCT02119286) compared UMEC 62.5 µg with placebo added to open-label ICS/LABA in symptomatic patients with COPD (modified Medical Research Council dyspnea scale score ≥ 2). A clinically important deterioration (CID) was defined as: a decrease from baseline of ≥ 100 mL in trough forced expiratory volume in 1 s (FEV1), an increase from baseline of ≥ 4 units in St George's Respiratory Questionnaire (SGRQ) total score, or a moderate/severe exacerbation. Risk of a first CID was evaluated in the intent-to-treat (ITT) population and in patients stratified by Global initiative for chronic Obstructive Lung Disease (GOLD) classification, exacerbation history and type of ICS/LABA therapy. Adverse events (AEs) were also assessed. RESULTS Overall, 1637 patients included in the ITT population received UMEC + ICS/LABA (n = 819) or placebo + ICS/LABA (n = 818). Additional bronchodilation with UMEC reduced the risk of a first CID by 45-58% in the ITT population and all subgroups analyzed compared with placebo (all p < 0.001). Improvements were observed in reducing FEV1 (69% risk reduction; p < 0.001) and exacerbation (47% risk reduction; p = 0.004) events in the ITT population. No significant reduction in risk of a SGRQ CID was observed. AE incidence was similar between treatment groups. CONCLUSION Symptomatic patients with COPD receiving ICS/LABA experience frequent deteriorations. Additional bronchodilation with UMEC significantly reduced the risk of CID and provided greater short-term stability versus continued ICS/LABA therapy in these patients. FUNDING GlaxoSmithKline (study number: 202067). Plain language summary available for this article.
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Affiliation(s)
- Ian P Naya
- Global Respiratory Franchise, GSK, Brentford, Middlesex, UK.
| | - Lee Tombs
- Precise Approach Ltd., Stockley Park West, Uxbridge, Middlesex, UK
| | - David A Lipson
- Respiratory Clinical Development, GSK, Collegeville, PA, USA
| | - Chris Compton
- Global Respiratory Franchise, GSK, Brentford, Middlesex, UK
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19
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Cazzola M, Calzetta L, Rogliani P, Page C, Matera MG. Impact of doxofylline in COPD: A pairwise meta-analysis. Pulm Pharmacol Ther 2018; 51:1-9. [PMID: 29705620 DOI: 10.1016/j.pupt.2018.04.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/24/2018] [Indexed: 02/07/2023]
Abstract
Doxofylline is an effective bronchodilator for relieving airway obstruction in patients with asthma or chronic obstructive pulmonary disease (COPD), and displays a better safety profile with respect to theophylline. Herein, we performed a pairwise meta-analysis of the currently available data to provide consistent and homogeneous findings on the impact of this xanthine in COPD patients. Results obtained from 820 patients were selected from 20 clinical trials. Meta-regression was performed to examine the source of heterogeneity between-studies and identify potential confounder covariates. The quality of the evidence was assessed by the GRADE system. Doxofylline induced a significant (P < 0.001) increase in forced expiratory volume in 1 s (FEV1) of 8.20% (95%CI 4.00-12.41; I2 93%) and 317 ml (95%CI 19-439; I2 87%) compared with baseline. The total administered dose of doxofylline significantly (P < 0.001) interacted with the size of the effect estimates detected for FEV1. Doxofylline induced a significant (P < 0.001), although moderate, increase in adverse events (AEs) frequency (proportion 0.03, 95%CI 0.02-0.04; I2 88%), but only epigastralgia, nausea, dyspepsia and headache were statistically significant (P < 0.05). The GRADE analysis indicated high quality of evidence (++++) for the impact of doxofylline on FEV1, and moderate quality of evidence (+++) for the safety profile in COPD patients. Doxofylline is an effective and safe medicine when administered to patients with COPD and can be considered as an alternative to theophylline.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Medicine, Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy.
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Halpin DMG. The Role of Tiotropium+Olodaterol Dual Bronchodilator Therapy in the Management of Chronic Obstructive Pulmonary Disease. Tuberc Respir Dis (Seoul) 2018; 81:13-18. [PMID: 29332320 PMCID: PMC5771742 DOI: 10.4046/trd.2017.0098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 12/31/2022] Open
Abstract
Bronchodilator therapy is central to the management of chronic obstructive pulmonary disease and are recommended as the preferred treatment by the Global Obstructive Lung Disease Initiative (GOLD). Long acting anti-muscarinics (LAMA) and long acting β₂ agonists (LABA) are both more effective than regular short-acting drugs but many patients remain symptomatic despite monotherapy with these drugs. Combination therapy with LAMA and LABA increases the therapeutic benefit while minimizing dose-dependent side effects of long-acting bronchodilator therapy. The TOviTO programme has investigated the benefits of treatment with a combination of tiotropium and olodaterol administered via a single inhaler. Tiotropium+olodaterol 5/5 μg significantly improved forced expiratory volume in 1 second (FEV₁) area under the curve from 0 to 3 hours, trough FEV₁ health status and breathlessness versus the mono-components and placebo. Tiotropium+olodaterol 5/5 μg also increased endurance time and reduced dynamic hyperinflation during constant work rate cycle ergometry. On the basis of these and other studies the 2017 GOLD report recommends escalating to dual bronchodilator therapy in patients in groups B and C if they remain symptomatic or continue to have exacerbations and as initial therapy for patients in group D.
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Affiliation(s)
- David M G Halpin
- Department of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, UK.
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21
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Xu J, He S, Han Y, Pan J, Cao L. Effects of modified pulmonary rehabilitation on patients with moderate to severe chronic obstructive pulmonary disease: A randomized controlled trail. Int J Nurs Sci 2017; 4:219-224. [PMID: 31406744 PMCID: PMC6626181 DOI: 10.1016/j.ijnss.2017.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/19/2017] [Accepted: 06/26/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jingjuan Xu
- Department of Scientific Research and Education, The Third Hospital Affiliated to Soochow University, Changzhou, People's Republic of China
| | - Shengnan He
- Department of Respiratory Diseases, The Third Hospital Affiliated to Soochow University, Changzhou, People's Republic of China
| | - Ying Han
- Department of Respiratory Diseases, The Third Hospital Affiliated to Soochow University, Changzhou, People's Republic of China
| | - Jingya Pan
- Department of Respiratory Diseases, The Third Hospital Affiliated to Soochow University, Changzhou, People's Republic of China
| | - Ling Cao
- Department of Respiratory Diseases, The Third Hospital Affiliated to Soochow University, Changzhou, People's Republic of China
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