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Cuperus LJA, van der Palen J, Aldenkamp A, van Huisstede A, Bischoff EWMA, van Boven JFM, Brijker F, Dik S, van Excel JAJM, Goosens M, van Hal PTW, Kuijvenhoven JC, Kunz LIZ, Vasbinder EC, Kerstjens HAM, In 't Veen JCCM. Adherence to single inhaler triple therapy and digital inhalers in Chronic Obstructive Pulmonary Disease: a literature review and protocol for a randomized controlled trial (TRICOLON study). BMC Pulm Med 2024; 24:317. [PMID: 38965541 PMCID: PMC11225120 DOI: 10.1186/s12890-024-03044-3] [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: 02/16/2024] [Accepted: 05/02/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Medication non-adherence is a significant problem in patients with Chronic Obstructive Pulmonary Disease (COPD). Efforts to address this issue are receiving increased attention. Simplifying treatment by prescribing single-inhaler triple therapy (SITT) as an alternative to multi-inhaler triple therapy (MITT) or with smart inhalers are often considered potential solutions. However, the actual impact of these innovations on adherence and clinical outcomes is unclear. METHODS To address this knowledge gap we first conducted a literature review focusing on two research questions: 1) the difference in adherence between SITT and MITT users in COPD, and 2) the effect of smart inhalers on adherence in COPD. Separate searches were conducted in PubMed and two authors independently assessed the articles. In addition, we present a protocol for a study to acquire knowledge for the gaps identified. RESULTS To address the first research question, 8 trials were selected for further review. All trials were observational, i.e. randomized controlled trials were lacking. Seven of these trials showed higher adherence and/or persistence in patients on SITT compared with patients on MITT. In addition, four studies showed a positive effect of SITT on various clinical outcomes. For the second research question, 11 trials were selected for review. While most of the studies showed a positive effect of smart inhalers on adherence, there was considerable variation in the results regarding their effect on other clinical outcomes. The TRICOLON (TRIple therapy COnvenience by the use of one or multipLe Inhalers and digital support in ChrONic Obstructive Pulmonary Disease) trial aims to improve understanding regarding the effectiveness of SITT and smart inhalers in enhancing adherence. This open-label, randomized, multi-center study will enroll COPD patients requiring triple therapy at ten participating hospitals. In total, 300 patients will be randomized into three groups: 1) MITT; 2) SITT; 3) SITT with digital support through a smart inhaler and an e-health platform. The follow-up period will be one year, during which three methods of measuring adherence will be used: smart inhaler data, self-reported data using the Test of Adherence to Inhalers (TAI) questionnaire, and drug analysis in scalp hair samples. Finally, differences in clinical outcomes between the study groups will be compared. DISCUSSION Our review suggests promising results concerning the effect of SITT, as opposed to MITT, and smart inhalers on adherence. However, the quality of evidence is limited due to the absence of randomized controlled trials and/or the short duration of follow-up in many studies. Moreover, its impact on clinical outcomes shows considerable variation. The TRICOLON trial aims to provide solid data on these frequently mentioned solutions to non-adherence in COPD. Collecting data in a well-designed randomized controlled trial is challenging, but the design of this trial addresses both the usefulness of SITT and smart inhalers while ensuring minimal interference in participants' daily lives. TRIAL REGISTRATION NCT05495698 (Clinicaltrials.gov), registered at 08-08-2022. Protocol version: version 5, date 27-02-2023.
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Affiliation(s)
- Liz J A Cuperus
- Pulmonology Department, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands.
- Pulmonology Department, University of Groningen, University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands.
- Pulmonology Department, Erasmus Medical Centre, Rotterdam, the Netherlands.
| | - Job van der Palen
- Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Arnoud Aldenkamp
- Department of Pulmonary Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Erik W M A Bischoff
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Folkert Brijker
- Department of Pulmonary Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Stephan Dik
- Department of Pulmonary Medicine, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | | | - Martijn Goosens
- Department of Pulmonary Medicine, Gelre Ziekenhuizen, Zutphen, The Netherlands
| | - Peter Th W van Hal
- Department of Respiratory Medicine, Van Weel-Bethesda Hospital, Dirksland, The Netherlands
| | - Jolanda C Kuijvenhoven
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Lisette I Z Kunz
- Department of Pulmonology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Erwin C Vasbinder
- Department of Clinical Pharmacy, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Huib A M Kerstjens
- Pulmonology Department, University of Groningen, University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
| | - Johannes C C M In 't Veen
- Pulmonology Department, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
- Pulmonology Department, Erasmus Medical Centre, Rotterdam, the Netherlands
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Whittaker HR, Torkpour A, Quint J. Eligibility of patients with chronic obstructive pulmonary disease for inclusion in randomised control trials investigating triple therapy: a study using routinely collected data. Respir Res 2024; 25:43. [PMID: 38238769 PMCID: PMC10797743 DOI: 10.1186/s12931-024-02672-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Randomised control trials (RCTs) with strict eligibility criteria can lead to trial populations not commonly seen in clinical practice. We described the proportion of people with chronic obstructive pulmonary disease (COPD) in England eligible for RCTs investigating treatment with triple therapy. METHODS MEDLINE and Clinicaltrials.gov were searched for RCTs investigating triple therapy and eligibility criteria for each trial were extracted. Using routinely collected primary care data from Clinical Practice Research Datalink Aurum linked with Hospital Episode Statistics, we defined a population of COPD patients registered at a general practice in England, who were ≥ 40 years old, and had a history of smoking. Inclusion date was January 1, 2020. Patients who died earlier or left the general practice were excluded. Eligibility criteria for each RCT was applied to the population of COPD patients and the proportion of patients meeting each trial eligibility criteria were described. RESULTS 26 RCTs investigating triple therapy were identified from the literature. The most common eligibility criteria were post-bronchodilator FEV1% predicted 30-80%, ≥ 2 moderate/≥ 1 severe exacerbations 12-months prior, no moderate exacerbations one-month prior and no severe exacerbations three-months prior, and the use of maintenance therapy or ICS use prior to inclusion. After applying each RCT eligibility criteria to our population of 79,810 COPD patients, a median of 11.2% [interquartile range (IQR) 1.8-17.4] of patients met eligibility criteria. The most discriminatory criteria included the presence exacerbations of COPD and previous COPD related medication use with a median of 67.6% (IQR 8.5-73.4) and 63% (IQR 69.3-38.4) of COPD patients not meeting these criteria, respectively. CONCLUSION Data from these RCTs may not be generalisable to the wider population of people with COPD seen in everyday clinical practice and real-world evidence studies are needed to supplement trials to understand effectiveness in all people with COPD.
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Affiliation(s)
| | - Aria Torkpour
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Jennifer Quint
- School of Public Health, Imperial College London, London, UK
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Calzetta L, Rogliani P. Bayesian or frequentist: there is no question when comparing single-inhaler triple therapies via network meta-analysis. Focus on fluticasone furoate/umeclidinium/vilanterol fixed-dose combination in chronic obstructive pulmonary disease. Expert Rev Respir Med 2023; 17:1273-1283. [PMID: 38318884 DOI: 10.1080/17476348.2024.2316167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/05/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVES Single-inhaler triple therapies (SITTs) have never been directly compared in randomized controlled trials (RCTs) in chronic obstructive pulmonary disease (COPD). Cochrane recommends the Bayesian approach for indirect comparisons but a frequentist network meta-analysis (NMA) reported superiority of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) over other SITT. We assessed the most appropriate inference method for NMA characterized by between-study heterogeneity on SITT in COPD. METHODS Bayesian and frequentist NMA were performed on RCTs investigating the effect of SITT on exacerbations and trough forced expiratory volume in the 1st second (FEV1) in COPD. RESULTS The included RCTs (ETHOS, FULFIL, IMPACT, KRONOS 200812) reported significant between-study heterogeneity (I2 > 99%, p < 0.001). The Bayesian random-effect NMA provided unbiased evidence that FF/UMEC/VI was not superior to other SITT on exacerbations and trough FEV1. The frequentist fixed-effect NMA indicated that FF/UMEC/VI was significantly (p < 0.05) more effective than other SITT, although results were affected by dispersion, asymmetry, and significant risk of bias. Frequentist random-effect NMA provided effect estimates rather similar but not equal to those of Bayesian approach. CONCLUSION Indirect comparison should be performed via Bayesian approach instead of frequentist inference with a fixed-effect model. Claiming the superiority of a specific medication over other therapies should be confirmed by findings originating from well-designed RCTs.
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Affiliation(s)
- Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Wang J, Wang P, Shao Y, He D. Advancing Treatment Strategies: A Comprehensive Review of Drug Delivery Innovations for Chronic Inflammatory Respiratory Diseases. Pharmaceutics 2023; 15:2151. [PMID: 37631365 PMCID: PMC10458134 DOI: 10.3390/pharmaceutics15082151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic inflammatory respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis, present ongoing challenges in terms of effective treatment and management. These diseases are characterized by persistent inflammation in the airways, leading to structural changes and compromised lung function. There are several treatments available for them, such as bronchodilators, immunomodulators, and oxygen therapy. However, there are still some shortcomings in the effectiveness and side effects of drugs. To achieve optimal therapeutic outcomes while minimizing systemic side effects, targeted therapies and precise drug delivery systems are crucial to the management of these diseases. This comprehensive review focuses on the role of drug delivery systems in chronic inflammatory respiratory diseases, particularly nanoparticle-based drug delivery systems, inhaled corticosteroids (ICSs), novel biologicals, gene therapy, and personalized medicine. By examining the latest advancements and strategies in these areas, we aim to provide a thorough understanding of the current landscape and future prospects for improving treatment outcomes in these challenging conditions.
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Affiliation(s)
- Junming Wang
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
| | - Pengfei Wang
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
| | - Yiru Shao
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
| | - Daikun He
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
- Department of General Practice, Jinshan Hospital, Fudan University, Shanghai 201508, China
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Deslee G, Fabry-Vendrand C, Poccardi N, Thabut G, Eteve Pitsaer C, Coriat A, Renaudat C, Maguire A, Pinto T. Use and persistence of single and multiple inhaler triple therapy prescribed for patients with COPD in France: a retrospective study on THIN database (OPTI study). BMJ Open Respir Res 2023; 10:10/1/e001585. [PMID: 37263738 DOI: 10.1136/bmjresp-2022-001585] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION From 2018 single inhaler triple therapy (SITT) became available in France to treat moderate-to-severe chronic obstructive pulmonary disease (COPD). Given its simplified inhaler use compared with multiple inhaler triple therapy (MITT), this therapeutic option has the potential to offer benefit in terms of improved persistence and adherence. Given the lack of real-world evidence of the effectiveness of triple therapy, this study was designed to evaluate the use of MITT and SITT in France and compare persistence. METHODS A retrospective cohort study was performed. Patients with COPD who initiated triple therapy between 1 July 2017 and 31 December 2019 were included from The Health Improvement Network, a large electronic medical database in France, which includes pharmacy data. A 60-day treatment gap defined discontinuation and thereby persistence. RESULTS A total of 3134 patients initiated triple therapy for COPD in the study period, among them 485 with SITT. In 2019, the rate of use of SITT was 28.2%. The mean age (67.3 years) and sex (44.2% female) of patients initiating triple therapy was similar between MITT and SITT, and most patients had escalated from dual therapy (84.1%). However, SITT was more frequently initiated by a pulmonologist (59.8%) and a higher prevalence of comorbid asthma was observed for SITT (47.0% vs 37.9%). Persistence was assessed among patients who did not discontinue after a single dispensation of triple therapy (n=1674). Median persistence was 181 days for SITT and 135 days for MITT, and the covariate-adjusted HR for persistence was 1.47 (p<0.001) and the estimated persistence at 1 year was 33% for SITT compared with 18% for MITT. DISCUSSION This study suggests that persistence was higher for the patients treated with SITT compared with MITT in France. Moreover, most patients initiated with triple therapy were previously treated with dual therapy and had exacerbations in the previous year.
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Affiliation(s)
- Gaétan Deslee
- Service de Pneumologie, INSERM UMRS-1250, CHU de Reims, Université Reims Champagne-Ardenne, CHU de Reims, Reims, France
| | | | | | | | | | | | | | | | - Thomas Pinto
- Médecin généraliste, Chef de clinique universitaire, Université de Paris, Paris, France
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Lin L, Liu C, Cheng W, Song Q, Zeng Y, Li X, Deng D, Liu D, Chen Y, Cai S, Chen P. Comparison of treatment persistence, adherence, and risk of exacerbation in patients with COPD treated with single-inhaler versus multiple-inhaler triple therapy: A prospective observational study in China. Front Pharmacol 2023; 14:1147985. [PMID: 37025493 PMCID: PMC10072324 DOI: 10.3389/fphar.2023.1147985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/03/2023] [Indexed: 04/08/2023] Open
Abstract
Aim: This study sought to compare treatment persistence, adherence, and risk of exacerbation among patients with COPD treated with single-inhaler triple therapy (SITT) and multiple-inhaler triple therapy (MITT) in the Chinese population. Methods: This was a multicenter, prospective observational study. Patients with COPD from ten hospitals in Hunan and Guangxi provinces in China were recruited from 1 January 2020 to 31 November 2021 for the study and were followed up for one year. Treatment persistence, adherence, and exacerbation rates during the 12-month follow-up were analyzed in COPD patients treated with SITT and MITT. Results: A total of 1,328 patients were enrolled for final analysis, including 535 (40.3%) patients treated with SITT and 793 (59.7%) treated with MITT. Of these patients, the mean age was 64.9 years and most patients were men. The mean CAT score was 15.2 ± 7.1, and the median (IQR) FEV1% was 54.4 (31.2). The SITT group had a higher mean CAT score, more patients with mMRC >1, and lower mean FEV1% and FEV1/FVC than the MITT patients. Moreover, the proportion of patients with ≥1 exacerbation in the previous year was higher in the SITT cohort. SITT patients had, compared to MITT patients, a higher proportion of adherence (proportion of days covered, PDC) ≥0.8 (86.5% vs. 79.8%; p = 0.006), higher treatment persistence [HR: 1.676 (1.356-2.071), p < 0.001], lower risk of moderate-to-severe exacerbation [HR: 0.729 (0.593-0.898), p = 0.003], and severe exacerbation [HR: 0.675 (0.515-0.875), p = 0.003], as well as reduced all-cause mortality risk [HR: 0.475 (0.237-0.952), p = 0.036] during the 12-month follow-up. Persistence was related to fewer future exacerbations and mortality than non-persistence in the SITT and MITT groups. Conclusion: Patients with COPD treated with SITT showed improved treatment persistence and adherence, as well as a reduction in the risk of moderate-to-severe exacerbation, severe exacerbation, and mortality compared to patients treated with MITT in the Chinese population. Clinical Trial Registration: https://www.chictr.org.cn/, identifier ChiCTR-POC-17010431.
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Affiliation(s)
- Ling Lin
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
| | - Cong Liu
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
| | - Wei Cheng
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
| | - Qing Song
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
| | - Yuqin Zeng
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
| | - Xin Li
- Division 4 of Occupational Diseases, Hunan Prevention and Treatment Institute for Occupational Diseases, Changsha, China
| | - Dingding Deng
- Department of Respiratory Medicine, The First Affiliated People’s Hospital, Shaoyang College, Shaoyang, China
| | - Dan Liu
- Department of Respiratory, The Eighth Hospital in Changsha, Hunan, China
| | - Yan Chen
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
| | - Shan Cai
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
| | - Ping Chen
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
- *Correspondence: Ping Chen,
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ICS/Ultra LABA in the Treatment of Obstructive Airway Diseases: A Consensus of Indian Experts. Adv Respir Med 2022; 90:407-424. [DOI: 10.3390/arm90050051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/26/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022]
Abstract
Inhaled corticosteroid and ultra-long-acting beta-agonist (ICS/uLABA) combination is a recent advancement in the armamentarium against obstructive airways diseases (OADs). The combination of ICS/uLABA has several advantages, creating a favorable landscape for its utilization. Fluticasone furoate/vilanterol trifenatate (FF/Vi) is one such example of an ICS/uLABA. It offers several benefits from both drugs, such as a convenient once daily dosing schedule; high lipophilicity; high receptor affinity of fluticasone furoate along with high functional selectivity and a quick onset of action of vilanterol. However, the Global Initiative for Asthma (GINA) as well as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines do not clearly define the positioning of ICS/uLABA compared to conventional ICS/LABAs. There are a few areas of uncertainty especially around the appropriate reliever strategy with ICS/uLABA in Asthma. The current consensus was planned with a group of Indian pulmonology experts to provide more clarity on the potential use of FF/Vi in Asthma and COPD. The clinical statements highlighted in this consensus manuscript address crucial clinical questions revolving around the efficacy and safety of FF/Vi as compared to conventional ICS/LABAs and identify the ideal patient profile for its use. This consensus paper also sheds light upon the appropriate reliever to be used along with FF/Vi in Asthma and the utilization of FF/Vi-based triple therapy in OADs. Expert recommendations mentioned in this paper will serve as guidance to pulmonologists as well as consultant physicians who are involved in providing care to OAD patients and will help them weigh the various factors that need to be taken into account while prescribing ICS/uLABA combination.
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Alcázar-Navarrete B, Jamart L, Sánchez-Covisa J, Juárez M, Graefenhain R, Sicras-Mainar A. Clinical Characteristics, Treatment Persistence, and Outcomes Among Patients With COPD Treated With Single- or Multiple-Inhaler Triple Therapy: A Retrospective Analysis in Spain. Chest 2022; 162:1017-1029. [DOI: 10.1016/j.chest.2022.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 01/22/2023] Open
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Zhang L, Wang X, Zhang Y, Chen W. Efficacy and Safety of Single Inhaler Triple Therapy Versus Separate Triple Therapy in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis. Clin Ther 2022; 44:859-873. [DOI: 10.1016/j.clinthera.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/03/2022] [Accepted: 04/08/2022] [Indexed: 11/16/2022]
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Cazzola M, Rogliani P, Calzetta L, Ora J, Matera MG. A single inhaler triple therapy fluticasone furoate/umeclidinium/vilanterol for the treatment of COPD. Expert Rev Clin Pharmacol 2022; 15:269-283. [PMID: 35475762 DOI: 10.1080/17512433.2022.2071700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Single inhaler triple therapy (SITT) with an inhaled corticosteroid, a long-acting β2-agonist, and a long-acting muscarinic antagonist is an effective and attractive therapeutic option codified in the recommendations of guidelines and treatment strategies for the management of COPD. AREAS COVERED : The preclinical and clinical development in COPD of fluticasone furoate (FF)/umeclidinium (UMEC)/vilanterol (VI) SITT and its use in the real world. EXPERT OPINION : Findings from phase III/IV trials and the use of FF/UMEC/VI in the real-world setting support the view that it may be a useful, safe, and cost-effective option for the maintenance treatment of COPD, especially when dealing with patients who are not adequately controlled with dual ICS/LABA or LAMA/LABA therapy. Only direct head-to-head comparisons will be able to establish whether FF/UMEC/VI may be preferable to the other SITTs approved for COPD due to its pharmacokinetic and pharmacodynamic characteristics and especially the fact that it is the only one that can be taken once-daily. In addition, there is a need for further studies, especially in the real world, to optimize the positioning of FF/UMEC/VI in the treatment of COPD, also considering the availability of FF/VI and UMEC/VI and the need for better differentiation between the three treatments.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Balmaceda C, Espinoza MA, Abbott T, Peters A. Cost-effectiveness analysis: fluticasone furoate/umeclidinium/vilanterol for the treatment of moderate to severe chronic obstructive pulmonary disease from the perspective of the Chilean public health system. Expert Rev Pharmacoecon Outcomes Res 2022; 22:743-751. [PMID: 35176212 DOI: 10.1080/14737167.2022.2044308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease characterized by long-term breathing problems and airflow limitations. International guidelines recommend using bronchodilators like long-acting beta- and muscarinic antagonists, and inhalational corticosteroids. OBJECTIVES The cost-effectiveness of single-inhaler triple therapy containing fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) was compared to the treatments Fluticasone Furoate/Vilanterol (FF/VI), Umeclidinio/Vilanterol (UMEC/VI) and Fluticasone Propionate 250 mcg/Salmeterol 25mcg + Tiotropio 18 mcg (FP/SAL/TIO) for patients with COPD from the Chilean public health system perspective. METHODS A cost-effectiveness analysis was performed, including a deterministic and probabilistic sensitivity analysis over a 25-year time horizon. Two scenarios were assessed to study the effect of a 3%-discount for costs and outcomes on FF/UMEC/VI. RESULTS The incremental cost-effectiveness (ICER) of FF/UMEC/VI versus FF/VI was $10,076/QALY, being a cost-effective alternative to a threshold of one Gross Domestic Product per capita (GDPpc), while versus FP/SAL/TIO the ICER increased to $50,288/QALY, showing to be a non-cost effective alternative to 1 GDPpc, but at a threshold of 3 GDPpc. CONCLUSION FF/UMEC/VI appears a cost-effective intervention for treating COPD compared to FF/VI. However, FF/UMEC/VI compared to FP/SAL/TIO showed an ICER above the threshold of 1 GDPpc, but, in comparison with lower price, the ICER was below 3 GDPpc.
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Affiliation(s)
- Carlos Balmaceda
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile
| | - Manuel A Espinoza
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile.,Department of Public Health, Faculty of Medicine, Pontificia Universidad Católica de Chile
| | - Tomas Abbott
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile
| | - Anne Peters
- Institute for Science and Innovation in Medicine, Faculty of Medicine Clínica Alemana, Universidad del Desarrollo
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12
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Aguilar-Shea AL, Gallardo-Mayo C. [COPD inhaled therapy narrative review]. Semergen 2021; 48:214-218. [PMID: 34493458 DOI: 10.1016/j.semerg.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
Inhaled therapy with long-acting bronchodilators is the base of pharmacological treatment in COPD. In order to find out those that offer better control, a search was carried out in Medline (Pubmed). Comparative studies of inhaler therapy in COPD patients were analyzed. The comparison between the fixed combination LABA/LAMA versus LABA/CI in non-exacerbating patients, revealed a better control with LABA/LAMA. Within the LABA/CI combinations, budesonide/formoterol combination offered better control. LAMA inhalers revealed no great differences, but when compared to LABA, it offered a better control. Regarding triple therapy in a single device, was superior to double therapy and to triple therapy in two devices, with no relevant differences among the available combinations.
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Affiliation(s)
- A L Aguilar-Shea
- Medicina Familiar y Comunitaria, Centro de Salud Puerta de Madrid, Atención Primaria de Madrid, Madrid, España.
| | - C Gallardo-Mayo
- Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario Infanta Leonor, Madrid, España
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13
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Jiang Y, Hu H, Leung SW. Comparative efficacy of single-inhaler triple therapies for COPD: A protocol for systematic review and network meta-analysis. PLoS One 2021; 16:e0255545. [PMID: 34351996 PMCID: PMC8341520 DOI: 10.1371/journal.pone.0255545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION 2021 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Reports recommends that patients with clinically significant symptoms and exacerbations of chronic obstructive pulmonary disease (COPD) should escalate to triple therapy, a combined use of inhaled corticosteroids (ICS), long-acting muscarinic antagonists (LAMA) and long-acting b2-agonists (LABA)(ICS/LAMA/LABA). Triple therapy in fixed-dose combinations (FDCs), i.e., combining ICS, LABA with LAMA and administrating by a single inhalation device, has appeared in recent years. This study aims to compare the efficacy of triple therapy in FDCs in treating patients with moderate to severe COPD. METHODS AND ANALYSES Literature search will be conducted on PubMed, Embase and Web of science, according to pre-specified and corresponding search strategies, for relevant reports published since the inception dates of the databases. Randomised controlled trials (RCT) which compared the triple therapy in FDCs with other pharmacological therapies will be included. The Cochrane risk of bias assessment tool (RoB 2) will be used to assess the RCT quality. The outcomes will be analyzed as rate ratios and mean differences under a random-effects model in a frequentist network meta-analysis (NMA). Additional statistical analyses including subgroup analysis, sensitivity analysis, and publication bias analysis will be performed to assess the evidential heterogeneity and robustness. The strength of evidence from the NMA will be evaluated with the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) methods. ETHICS AND DISSEMINATION No ethics approval is required as this systematic review and network meta-analysis do not collect confidential personal data and do not carry out interventions in treating patients. PROTOCOL REGISTRATION NUMBER CRD42021240823.
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Affiliation(s)
- Yixuan Jiang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau SAR, China
| | - Siu-wai Leung
- Shenzhen Institute of Artificial Intelligence and Robotics for Society, Shenzhen, China
- Edinburgh Bayes Centre for AI Research in Shenzhen, College of Science and Engineering, University of Edinburgh, Edinburgh, United Kingdom
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14
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Bourdin A, Molinari N, Ferguson GT, Singh B, Siddiqui MK, Holmgren U, Ouwens M, Jenkins M, De Nigris E. Efficacy and Safety of Budesonide/Glycopyrronium/Formoterol Fumarate versus Other Triple Combinations in COPD: A Systematic Literature Review and Network Meta-analysis. Adv Ther 2021; 38:3089-3112. [PMID: 33929661 PMCID: PMC8189959 DOI: 10.1007/s12325-021-01703-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/10/2021] [Indexed: 11/30/2022]
Abstract
In patients with chronic obstructive pulmonary disease (COPD) who experience further exacerbations or symptoms, despite being prescribed dual long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) or inhaled corticosteroid (ICS)/LABA therapies, triple ICS/LAMA/LABA therapy is recommended. A previous network meta-analysis showed comparable efficacy of the ICS/LAMA/LABA, budesonide/glycopyrronium bromide/formoterol fumarate (BUD/GLY/FOR) 320/18/9.6 µg, to other fixed-dose and open combination triple therapies at 24 weeks in COPD. Subsequently, the ETHOS study was published, including data for 8509 patients, assessing the efficacy and safety of BUD/GLY/FOR over 52 weeks. This network meta-analysis (NMA) was conducted to compare the relative efficacy, safety, and tolerability of BUD/GLY/FOR 320/18/9.6 µg with other fixed-dose and open combination triple therapies in COPD over 52 weeks, including data from ETHOS. A systematic literature review was conducted to identify ≥ 10-week randomized controlled trials, including ≥ 1 fixed-dose or open combination triple-therapy arm, in patients with moderate-to-very severe COPD. The methodologic quality and risk of bias of included studies were assessed. Study results were combined using a three-level hierarchical Bayesian NMA model to assess efficacy and safety outcomes at or over 24 and 52 weeks. Meta-regression and sensitivity analyses were used to assess heterogeneity across studies. Nineteen studies (n = 37,741 patients) met the inclusion criteria of the review; 15 contributed to the base case network. LAMA/LABA dual combinations were combined as a single treatment group to create a connected network. Across all outcomes for exacerbations, lung function, symptoms, health-related quality of life, safety, and tolerability, the efficacy and safety of BUD/GLY/FOR were comparable to those of other triple ICS/LAMA/LABA fixed-dose (fluticasone furoate/umeclidinium/vilanterol and beclomethasone dipropionate/glycopyrronium bromide/formoterol fumarate) and open combinations at or over 24 and 52 weeks. Sensitivity analyses and meta-regression results for exacerbation outcomes were broadly in line with the base case NMA. In this NMA, BUD/GLY/FOR 320/18/9.6 μg showed comparable efficacy versus other ICS/LAMA/LABA fixed-dose or open combination therapies in terms of reducing exacerbation rates and improving lung function, symptoms and health-related quality of life in patients with moderate-to-very-severe COPD, in line with previously published meta-analysis results of triple combinations in COPD. The safety and tolerability profile of BUD/GLY/FOR was also found to be comparable to other triple combination therapies.
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Affiliation(s)
- Arnaud Bourdin
- Department of Respiratory Diseases, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France.
- Département Pneumologie et Addictologie, CHU de Montpellier-Hôpital Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France.
| | - Nicolas Molinari
- IMAG, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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15
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Population Pharmacokinetic Analysis of Fluticasone Furoate/Umeclidinium Bromide/Vilanterol in Patients with Chronic Obstructive Pulmonary Disease. Clin Pharmacokinet 2021; 59:67-79. [PMID: 31321713 PMCID: PMC6995987 DOI: 10.1007/s40262-019-00794-w] [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: 10/26/2022]
Abstract
BACKGROUND Population pharmacokinetic methods were used to characterize the pharmacokinetics of fluticasone furoate (FF), umeclidinium (UMEC), and vilanterol (VI) in patients with chronic obstructive pulmonary disease (COPD) when administered as a fixed-dose combination via a single closed inhaler. METHODS Plasma concentration data from three studies were analyzed using non-linear mixed-effects modeling in NONMEM®. RESULTS The pooled dataset consisted of 2948, 2589, and 3331 FF, UMEC, and VI observations from 714, 622, and 817 patients with COPD, respectively. There were 41%, 13%, and 21% of observations below the quantification limit for FF, UMEC, and VI, respectively. The pharmacokinetics of FF, UMEC, and VI were all adequately described by a two-compartment model with first-order absorption. The following covariates were statistically significant, but none were considered to be clinically relevant. For FF, Japanese heritage and FF/VI treatment on apparent inhaled clearance (CL/F) with FF CL/F 35% lower in patients of Japanese heritage across all treatments and FF CL/F 42% higher in patients with COPD following FF/VI administration. This is in line with the product label. For UMEC, weight, age, and smoking status on CL/F and weight on apparent volume of distribution (V2/F) with every 10% increase in age from 60 years of age leading to approximately a 6% decrease in UMEC CL/F and every 10% increase in weight from 70 kg leading to approximately a 6% increase in UMEC CL/F and approximately an 8% increase in UMEC V2/F. For a subject with COPD who smoked, UMEC CL/F was 28% higher. For VI, weight on CL/F and smoking status on V2/F with an approximately 4% increase in VI CL/F for every 10% increase in weight from 70 kg, and for a subject with COPD who smoked, VI V2/F was 46% higher. The majority of these covariates have been previously identified in historical analyses. None of these effects were clinically relevant in terms of systemic exposures and do not warrant dose adjustment. CONCLUSIONS All FF, UMEC, and VI plasma concentrations were well interspersed with historical data and were all adequately described by a two-compartment model with first-order absorption. There were no clinically relevant differences in FF, UMEC, or VI systemic exposures when administered as FF/UMEC/VI, FF/VI + UMEC, or the dual combinations FF/VI and/or UMEC/VI.
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16
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Lee HW, Kim HJ, Jang EJ, Lee CH. Comparisons of Efficacy and Safety between Triple (Inhaled Corticosteroid/Long-Acting Muscarinic Antagonist/Long-Acting Beta-Agonist) Therapies in Chronic Obstructive Pulmonary Disease: Systematic Review and Bayesian Network Meta-Analysis. Respiration 2021; 100:631-643. [PMID: 33971649 DOI: 10.1159/000515133] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Various combinations of inhaled corticosteroid (ICS), long-acting muscarinic antagonist (LAMA), and long-acting beta-agonist (LABA) have been used as triple therapy for stable chronic obstructive pulmonary disease (COPD). OBJECTIVE Our study was conducted to answer whether there were significant differences among various combinations in efficacy, for reducing exacerbation or mortality, and in safety, for increasing cardiovascular events or pneumonia. METHOD We searched parallel-group randomized controlled trials (RCTs) comparing ICS/LAMA/LABA with other inhaled drugs in patients with stable COPD for at least 12 weeks in PubMed, EMBASE, the Cochrane Library, and clinical trial registries from inception to December 31, 2019. We conducted a network meta-analysis with Bayesian statistics using a random-effects model with heterogeneous variance structure (PROSPERO, CRD42019126757). RESULTS Nine different combinations of ICS/LAMA/LABA were identified in 21 RCTs containing 29,892 patients with moderate to very severe COPD. We could not find any significant evidence suggesting a better treatment for reducing total exacerbations or all-cause mortality among ICS/LAMA/LABA combinations. There were also no significant differences in moderate to severe exacerbation, COPD-related mortality, or cardiovascular disease-related mortality among ICS/LAMA/LABA combinations, and the risk of major adverse cardiovascular events was not different. A significantly lower risk of pneumonia was found in fluticasone propionate (FP)/glycopyrrolate/salmeterol (SAL) than FP/tiotropium/SAL {median odds ratio [OR] (95% credible interval [CrI]) = 0 [0-0.72]} and FP/umeclidinium/SAL {median OR (95% Crl) = 0 [0-0.97]}. CONCLUSION There were no significant differences in clinical outcomes, including acute exacerbation and all-cause mortality among various ICS/LAMA/LABA combinations in patients with moderate to very severe COPD.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Dongjak-gu, Seoul, Republic of Korea
| | - Hyung Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Jongno-Gu, Seoul, Republic of Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Jongno-Gu, Seoul, Republic of Korea
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17
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Papaioannou AI, Loukides S, Bakakos P, Kosmas EN, Rovina N, Steiropoulos P, Fouka E, Hillas G, Patentalakis G, Kouvela M, Tzanakis N. Dual Bronchodilator in the Era of Triple Therapy. Int J Chron Obstruct Pulmon Dis 2020; 15:2695-2705. [PMID: 33149567 PMCID: PMC7604249 DOI: 10.2147/copd.s273987] [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: 07/30/2020] [Accepted: 09/23/2020] [Indexed: 01/18/2023] Open
Abstract
Pharmacological medications used for the treatment of COPD patients have increased significantly. Long-acting bronchodilators have been recognized as the mainstay of the treatment of stable COPD, while ICS are usually added in patients with COPD who experience exacerbations, despite bronchodilator treatment. In the latest years, several studies have been published showing the beneficial effect of adding ICS on dual bronchodilation in patients suffering from more severe disease comparing triple therapy with several therapeutic regiments including dual bronchodilation and providing a message that this triple therapy might be more appropriate for COPD patients. However, not all COPD patients have a desirable response to ICS treatment while long-term ICS use in COPD is associated with several side effects. In this report, we aimed to provide a review of the current knowledge on the importance of dual bronchodilation on COPD patients and to compare its use with triple therapy, by covering a wide spectrum of topics. Finally, we propose an algorithm on performing treatment step up from dual bronchodilation to triple therapy and step down from triple to double bronchodilation considering the current evidence.
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Affiliation(s)
- Andriana I Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Petros Bakakos
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | | | - Nikoletta Rovina
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangellia Fouka
- Respiratory Medicine Department, Aristotle University of Thessaloniki, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Georgios Hillas
- 5th Respiratory Medicine Department, Sotiria Chest Hospital, Athens, Greece
| | | | - Marousa Kouvela
- 3rd Department of Medicine, Athens Medical School, Athens, Greece
| | - Nikos Tzanakis
- Department of Thoracic Medicine, Faculty of Medicine, University of Crete, Crete, Greece
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18
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López-Campos JL, Alcázar Navarrete B, Riesco Miranda JA, Cosío BG, de-Torres JP, Celli B, Jiménez-Ruiz CA, Casanova Macario C. A Delphi Consensus Document on the Use of Single-Inhaler Fixed-Dose Triple Therapies in COPD Patients. Int J Chron Obstruct Pulmon Dis 2020; 15:1801-1811. [PMID: 32884252 PMCID: PMC7435744 DOI: 10.2147/copd.s258818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/02/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction Despite the evidence provided by clinical trials, there are some uncertainties and controversies regarding the use of triple inhaled therapy. With the aim of evaluating clinical practice in specialized respiratory units, a Delphi consensus document was implemented on the use of single-inhaler fixed-dose triple therapies after 1 year of use in Spain. Methods A scientific committee of COPD experts defined a thematic index, guided a systematic literature review and helped design the Delphi questionnaire. This was sent to the other 45 COPD experts between April and June 2019. Agreement/disagreement on 58 statements was tested in two rounds using a Likert scale. Replies were classified as a consensus when ≥80% of the panelists agreed; a majority when a degree of agreement of ≥66% was reached; and divergence if agreement was <66%. Results After two rounds, 44.44% of the statements reached consensus, 14.81% reached majority and 40.74% were divergent. Panelists agreed that escalating from double bronchodilation should be phenotype-based and aim to prevent exacerbations but not for improving symptoms. The addition of an antimuscarinic to inhaled corticosteroids combinations achieves improvement in lung function, symptoms and exacerbation prevention. Main safety concerns included the increased risk of pneumonia as compared to bronchodilator therapies, with similar cardiovascular effects. There was no consensus agreement on patient type response based on blood eosinophil counts or obstruction severity. Conclusion The low degree of consensus among panelists may reflect the complexity of severe COPD management. The information provided here may be useful to clinicians implementing personalized medicine for COPD patients.
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Affiliation(s)
- José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Juan Antonio Riesco Miranda
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario de Cáceres, Cáceres, Spain
| | - Borja G Cosío
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Spain
| | | | - Bartolomé Celli
- Brigham and Women’s Hospital, Harvard Medical School Boston, Boston, MA, USA
| | | | - Ciro Casanova Macario
- Servicio de Neumología-Unidad de Investigación, Hospital Universitario La Candelaria, Universidad de La Laguna, La Laguna, Spain
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19
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Calzetta L, Matera MG, Rogliani P, Cazzola M. The role of triple therapy in the management of COPD. Expert Rev Clin Pharmacol 2020; 13:865-874. [DOI: 10.1080/17512433.2020.1787830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Luigino Calzetta
- Unit of Respiratory Disease and Lung Function Department Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Unit of Pharmacology, Department Experimental Medicine, Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Unit of Pharmacology, Department Experimental Medicine, Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
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20
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Lopez-Campos JL, Carrasco-Hernandez L, Quintana-Gallego E, Calero-Acuña C, Márquez-Martín E, Ortega-Ruiz F, Soriano JB. Triple therapy for COPD: a crude analysis from a systematic review of the evidence. Ther Adv Respir Dis 2020; 13:1753466619885522. [PMID: 31694491 PMCID: PMC7000908 DOI: 10.1177/1753466619885522] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We systematically reviewed the current knowledge on fixed-dose triple therapies
for the treatment of chronic obstructive pulmonary disease (COPD), with a
specific focus on its efficacy versus single bronchodilation,
double fixed dose combinations, and open triple therapies. Articles were
retrieved from PubMed, Embase, and Scopus up to 3 August 2018. We selected
articles with randomized controlled or crossover design conducted in patients
with COPD and published as full-length articles or scientific letters,
evaluating triple therapy combinations in a single or different inhaler, and
with efficacy data versus monocomponents, double combinations,
or open triple therapies. Our systematic search reported 108 articles, of which
24 trials were finally selected for the analysis. A total of 7 studies with
fixed dose triple therapy combinations, and 17 studies with open triple
therapies combinations. Triple therapy showed improvements in lung function
[trough forced expiratory volume (FEV1) ranging from not significant
(NS) to 147 ml], health status using the St. George’s Respiratory Questionnaire
[(SGRQ) from NS to 8.8 points], and exacerbations [risk ratio (RR) from NS to
0.59 for all exacerbations] versus single or double therapies
with a variability in the response, depending the specific combination, and the
comparison group. The proportion of adverse effects was similar between study
groups, the exception being the increase in pneumonia for some inhaled
corticosteroid (ICS) containing groups. The reviews of this paper are available via the supplementary material
section.
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Affiliation(s)
- Jose Luis Lopez-Campos
- Instituto de Biomedicina de Sevilla (IBiS), Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Avda. Manuel Siurot, s/n., Seville, 41013, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Carrasco-Hernandez
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Esther Quintana-Gallego
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Calero-Acuña
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Eduardo Márquez-Martín
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco Ortega-Ruiz
- IBiS, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan B Soriano
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Madrid, España
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21
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Efficacy of Budesonide/Glycopyrronium/Formoterol Fumarate Metered Dose Inhaler (BGF MDI) Versus Other Inhaled Corticosteroid/Long-Acting Muscarinic Antagonist/Long-Acting β 2-Agonist (ICS/LAMA/LABA) Triple Combinations in COPD: A Systematic Literature Review and Network Meta-analysis. Adv Ther 2020; 37:2956-2975. [PMID: 32335859 PMCID: PMC7467454 DOI: 10.1007/s12325-020-01311-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Triple inhaled corticosteroid/long-acting muscarinic antagonist/long-acting β2-agonist (ICS/LAMA/LABA) combination therapy is recommended for patients with chronic obstructive pulmonary disease (COPD) who experience further exacerbations/symptoms on dual LAMA/LABA or ICS/LABA therapy. The relative efficacy of budesonide/glycopyrronium/formoterol fumarate metered dose inhaler 320/18/9.6 µg (BGF MDI) in COPD was compared with other ICS/LAMA/LABA fixed-dose and open combination therapies in a network meta-analysis (NMA). METHODS A systematic literature review was conducted to identify randomized controlled trials of at least 10-week duration, including at least one fixed-dose or open combination triple therapy arm, in patients with moderate to very severe COPD. Studies were assessed for methodological quality and risk of bias. A three-level hierarchical Bayesian NMA model was used to determine the exacerbation rate per patient per year as well as the following outcomes at week 24: changes from baseline in pre-dose trough forced expiratory volume in 1 s (FEV1), post-dose peak FEV1, and St. George's Respiratory Questionnaire (SGRQ) total score; proportion of SGRQ responders; and Transition Dyspnea Index focal score. Change from baseline in rescue medication use over weeks 12-24 was also analyzed. Meta-regression and sensitivity analyses were used to assess heterogeneity across studies. RESULTS Eighteen studies (n = 29,232 patients) contributed to the NMA. ICS/LABA dual combinations were combined as a single treatment group to create a connected network. Across all outcomes, there were no statistically significant differences between BGF MDI and other triple ICS/LAMA/LABA fixed-dose (fluticasone furoate/umeclidinium/vilanterol and beclomethasone dipropionate/glycopyrronium/formoterol fumarate) and open combinations with data available within the network. Results from sensitivity analyses and meta-regression were consistent with the base-case scenario. CONCLUSION This NMA suggested that BGF MDI has comparable efficacy to other ICS/LAMA/LABA fixed-dose and open triple combination therapies in reducing exacerbations and improving lung function and symptoms in patients with moderate to very severe COPD. Further research is warranted as additional evidence regarding triple therapies, especially fixed-dose combinations, becomes available.
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La prescripción con visado de la triple terapia en combinación a dosis fija en España. Arch Bronconeumol 2020; 56:271-272. [DOI: 10.1016/j.arbres.2019.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 11/17/2022]
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López-Campos JL, Peces-Barba G, Jiménez-Ruiz CA. Controlled Prescription of Triple Fixed-Dose Combination Therapy in Spain. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.arbr.2019.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ruano-Raviña A, Fernández-Villar A, López-Campos JL. Coping With Low Mortality and Exacerbation Rate Differences Between COPD Triple Therapy Studies, and a Proposal for Upcoming Studies. Arch Bronconeumol 2020; 56:336-338. [PMID: 31898995 DOI: 10.1016/j.arbres.2019.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/31/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Alberto Ruano-Raviña
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Alberto Fernández-Villar
- Grupo NeumoVigo I+i, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Servicio de Neumología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
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López-Campos JL, Carrasco-Hernández L, Román Rodríguez L, Quintana-Gallego E, Carmona Bernal C, Alcázar Navarrete B. The clinical implications of triple therapy in fixed-dose combination in COPD: from the trial to the patient. Arch Bronconeumol 2020; 56:242-248. [PMID: 35373739 DOI: 10.1016/j.arbr.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/02/2019] [Indexed: 11/19/2022]
Abstract
The emergence of a fixed-dose combination (FDC) of a long-acting ß2-agonist (LABA), a long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid (ICS) in a single inhalation device has changed the approach to inhaled therapy. Although clinical trials describe the efficacy and safety of these FDCs, their use in daily clinical practice can present challenges for the clinician in two specific scenarios. In patients who are already receiving triple therapy via different devices, switching to FDCs could confer benefits by reducing critical errors in the management of inhalers, improving therapeutic adherence, and lowering costs, while maintaining the same clinical efficacy. In patients who are not receiving triple therapy in different devices and who require a change in treatment, triple therapy FDC has shown benefits in clinical trials. Although methodological differences among the trials advise against direct comparison, clinical results show good efficacy, but also considerable variability, and a number of clinical outcomes have yet to be explored. In the future, trials must be developed to complete clinical efficacy data. Real-world efficacy trials are needed, and studies must be designed to determine the profile of patients who present a greater therapeutic response to each FDC in order to pave the way towards more personalized treatment.
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Affiliation(s)
- José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Laura Carrasco-Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Lucas Román Rodríguez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Esther Quintana-Gallego
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Carmona Bernal
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Bernardino Alcázar Navarrete
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Neumología, Hospital de Alta Resolución de Loja, Loja, Granada, Spain
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Albertson TE, Chenoweth JA, Pearson SJ, Murin S. The pharmacological management of asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). Expert Opin Pharmacother 2020; 21:213-231. [PMID: 31955671 DOI: 10.1080/14656566.2019.1701656] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) is a disease phenotype that shares T helper lymphocyte cell Th1/neutrophilic/non-Type-2 Inflammation pathways thought to be key in COPD and Th2/eosinophilic/Type-2 inflammatory pathways of asthma. The pharmacology of treating ACOS is challenging in severe circumstances.Areas covered: This review evaluates the stepwise treatment of ACOS using pharmacological treatments used in both COPD and asthma. The most common medications involve the same inhalers used to treat COPD and asthma patients. Advanced stepwise therapies for ACOS patients are based on patient characteristics and biomarkers. Very few clinical trials exist that focus specifically on ACOS patients.Expert opinion: After inhalers, advanced therapies including phosphodiesterase inhibitors, macrolides, N-acetylcysteine and statin therapy for those ACOS patients with a COPD appearance and exacerbations are available. In atopic ACOS patients with exacerbations, advanced asthma therapies (leukotriene receptor antagonists and synthesis blocking agents.) are used. ACOS patients with elevated blood eosinophil/IgE levels are considered for immunotherapy or therapeutic monoclonal antibodies blocking specific Th2/Type-2 interleukins or IgE. Symptom control, stabilization/improvement in pulmonary function and reduced exacerbations are the metrics of success. More pharmacological trials of ACOS patients are needed to better understand which patients benefit from specific treatments.Abbreviations: 5-LOi: 5-lipoxygenase inhibitor; ACOS: asthma - COPD overlap syndrome; B2AR: Beta2 adrenergic receptors; cAMP: cyclic adenosine monophosphate; cGMP: cyclic guanosine monophosphate; CI: confidence interval; COPD: chronic obstructive pulmonary disease; CRS : chronic rhinosinusitis; cys-LT: cysteinyl leukotrienes; DPI: dry powder inhaler; EMA: European Medicines Agency; FDA: US Food and Drug Administration; FDC: fixed-dose combination; FeNO: exhaled nitric oxide; FEV1: forced expiratory volume in one second; FVC: forced vital capacity; GM-CSF: granulocyte-macrophage colony-stimulating factor; ICS : inhaled corticosteroids; IL: interleukin; ILC2: Type 2 innate lymphoid cells; IP3: Inositol triphosphate; IRR: incidence rate ratio; KOLD: Korean Obstructive Lung Disease; LABA: long-acting B2 adrenergic receptor agonist; LAMA: long-acting muscarinic receptor antagonist; LRA: leukotriene receptor antagonist; LT: leukotrienes; MDI: metered-dose inhalers; MN: M-subtype muscarinic receptors; MRA: muscarinic receptor antagonist; NAC: N-acetylcysteine; NEB: nebulization; OR: odds ratio; PDE: phosphodiesterase; PEFR: peak expiratory flow rate; PGD2: prostaglandin D2; PRN: as needed; RR: risk ratio; SABA: short-acting B2 adrenergic receptor agonist; SAMA: short-acting muscarinic receptor antagonist; SDMI: spring-driven mist inhaler; Th1: T helper cell 1 lymphocyte; Th2: T helper cell 2 lymphocytes; TNF-α: tumor necrosis factor alpha; US : United States.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Skyler J Pearson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Susan Murin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
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The Clinical Implications of Triple Therapy in Fixed-Dose Combination in COPD: From the Trial to the Patient. Arch Bronconeumol 2020. [PMID: 31983474 DOI: 10.1016/j.arbres.2019.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The emergence of a fixed-dose combination (FDC) of a long-acting β2-agonists (LABAS), a long-acting anticholinergic agent (LAMA), and an inhaled corticosteroid (ICS) in a single inhalation device has changed the approach to inhaled therapy. Although clinical trials describe the efficacy and safety of these FDCs, their use in daily clinical practice can present challenges for the clinician in two specific scenarios. In patients who are already receiving triple therapy via different devices, switching to FDCs could confer benefits by reducing critical errors in the management of inhalers, improving therapeutic adherence, and lowering costs, while maintaining the same clinical efficacy. In patients who are not receiving triple therapy in different devices and who require a change in treatment, triple therapy FDC has shown benefits in clinical trials. Although methodological differences among the trials advise against direct comparison, clinical results show good efficacy, but also considerable variability, and a number of clinical outcomes have yet to be explored. In the future, trials must be developed to complete clinical efficacy data. Real-world efficacy trials are needed, and studies must be designed to determine the profile of patients who present a greater therapeutic response to each FDC in order to pave to way towards more personalized treatment.
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Bourbeau J, Bhutani M, Hernandez P, Aaron SD, Balter M, Beauchesne MF, D’Urzo A, Goldstein R, Kaplan A, Maltais F, Sin DD, Marciniuk DD. Canadian Thoracic Society Clinical Practice Guideline on pharmacotherapy in patients with COPD – 2019 update of evidence. CANADIAN JOURNAL OF RESPIRATORY CRITICAL CARE AND SLEEP MEDICINE 2019. [DOI: 10.1080/24745332.2019.1668652] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Jean Bourbeau
- Research Institute of the McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Mohit Bhutani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shawn D. Aaron
- The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Meyer Balter
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Anthony D’Urzo
- Primary Care Lung Clinic, University of Toronto, Toronto, Ontario, Canada
| | - Roger Goldstein
- West Park Healthcare Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, Ontario, Canada
| | - François Maltais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Quebec, Canada
| | - Don D. Sin
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Darcy D. Marciniuk
- Respiratory Research Centre, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Aguilar-Shea AL, Bonis J. COPD from an everyday primary care point of view. J Family Med Prim Care 2019; 8:2644-2650. [PMID: 31548948 PMCID: PMC6753803 DOI: 10.4103/jfmpc.jfmpc_477_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 06/20/2019] [Accepted: 07/12/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction: The purpose of this study is to use real world evidence on treatment use to evaluate drug superiority within the same treatment group. Methods: Retrospective cohort analysis using the Spanish Database for Pharmacoepidemiological Research in Primary Care (BIFAP). Data includes longitudinal routine clinical data extracted from practice records of 7,890,485 patients. All subjects with an incident diagnosis of COPD in the database BIFAP between January 1 2010 and December 31 2012 were included in the cohort study. Cox regression analysis was performed to compare the hazard of COPD exacerbation outcome of the four principal cohorts (no therapy, monotherapy, double therapies with and without corticoids, and triple therapy) and within each principal cohort between the different treatment combinations. Results: 27,739 patients with COPD were included in the analysis. The median age was 64 years, male proportion was 69% and 70% were smokers. 58,042.9 person--years of follow-up were obtained for the cohort with a mean follow-up of 2.09 years per subject. The strongest factor associated with an increased risk of exacerbation was suffering an exacerbation the previous year (HR = 1.82[1.76--1.87 95%CI]). No differences were found between the most frequent monotherapies, double therapies without corticoid, or triple therapy. When comparing the different combinations of double therapies with corticoid, salmeterol/fluticasone combination (HR = 1.16[1.08--1.24]) revealed a higher adjusted hazard of exacerbation when compared with formoterol/budesonide. Conclusions: Treatment with a combination of budesonide/formoterol was associated with lower exacerbations than the treatment with fluticasone/salmeterol. The analysis did not reveal any differences in terms of exacerbation in monotherapy, double therapy without corticoids, and triple therapy combinations.
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Affiliation(s)
| | - Julio Bonis
- Base de Datos para la Investigación Farmacoepidemiológica en Atención Primaria, Spanish Agency of Medicines and Medical Devices, Madrid, Spain
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Lai CC, Chen CH, Lin CYH, Wang CY, Wang YH. The effects of single inhaler triple therapy vs single inhaler dual therapy or separate triple therapy for the management of chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Int J Chron Obstruct Pulmon Dis 2019; 14:1539-1548. [PMID: 31371939 PMCID: PMC6628970 DOI: 10.2147/copd.s200846] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/10/2019] [Indexed: 12/20/2022] Open
Abstract
Background This study aims to compare the effects of single inhaler triple therapy comprised of inhaled corticosteroids (ICSs), long-acting β2-agonists (LABAs), and long-acting muscarinic receptor antagonists (LAMAs) with dual therapies comprised of either LABA/LAMA, ICS/LABA or separate ICS/LABA plus LAMA triple therapy. Methods The Pubmed, Embase, and Cochrane databases were searched up to October 31st 2018. Only randomized controlled trials were included in the meta-analysis. The primary outcome was the rate of moderate-to-severe chronic obstructive pulmonary disease (COPD) exacerbations. Results Seven studies fulfilling the inclusion criteria were included in the meta-analysis. Single inhaler triple therapy was associated with a significantly lower risk of COPD exacerbation compared with LABA/LAMA (rate ratio, 0.69; 95% confidence interval [CI] 0.55 to 0.87, I2=85%), and ICS/LABA (rate ratio, 0.81; 95% CI 0.73 to 0.89, I2=29%) dual therapy. Single inhaler triple therapy led to a more significant improvement in lung function and quality of life compared with LABA/LAMA and ICS/LABA dual therapy. Single inhaler triple therapy was associated with a higher risk of pneumonia compared with LABA/LAMA (risk ratio, 1.38, 95% CI 1.14 to 1.67, I2=0) dual therapy. Conclusions The use of single inhaler triple therapy for COPD patients can result in lower rates of moderate or severe exacerbations of COPD as well as improved lung function and quality of life compared with dual therapy with LABA/LAMA or ICS/LABA.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Cheng-Hsin Chen
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Charlotte Yu Hsuan Lin
- Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA, USA
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ya-Hui Wang
- Medical Research Center, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
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Gaduzo S, McGovern V, Roberts J, Scullion JE, Singh D. When to use single-inhaler triple therapy in COPD: a practical approach for primary care health care professionals. Int J Chron Obstruct Pulmon Dis 2019; 14:391-401. [PMID: 30863039 PMCID: PMC6388781 DOI: 10.2147/copd.s173901] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
While single-inhaler triple therapy (SITT) devices were not available when the Global Initiative for Chronic Obstructive Lung Disease strategy and National Institute for Health and Care Excellence guidelines were developed, two devices are now available in the UK. This paper offers practical, patient-focused advice to optimize placement of SITT in the management of COPD. A survey of UK health care professionals (HCPs) identified issues around, and attitudes toward, SITT, which informed a multidisciplinary expert panel’s discussions. The survey confirmed the need to clarify the place of SITT in COPD management. The panel suggested three criteria, any one of which identifies a high-risk patient where escalation to triple therapy from monotherapy or double combination treatment is appropriate: 1) at least two exacerbations treated with oral corticosteroids, antibiotics, or both in the previous year; 2) at least one severe exacerbation that required hospital admission in the previous year; 3) one exacerbation a year on a repeated basis for 2 consecutive years. Appropriate non-pharmacological management is essential for all patients and should be considered before stepping up treatment. Regular review is essential. During each review, HCPs should consider stepping treatment up or down. If patients exacerbate despite adhering to triple therapy, an individualized approach should be considered if the inhaled corticosteroid (ICS) confers benefit or causes side effects. In this situation, the blood eosinophil count could aid decision making. ICSs should be continued when the history suggests that asthma overlaps with COPD. Training, counseling, and education should be individualized. HCPs should consider referral: 1) when there is limited response to treatment and persistent exacerbations; 2) where there is diagnostic uncertainty or suspected comorbidity; 3) whenever they feel “out of their depth.” Overall, the panel concurred that when used correctly, SITT has the potential to improve adherence, symptom control, and quality of life, and reduce exacerbations. Studies using real-world evidence need to confirm these benefits.
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Affiliation(s)
- S Gaduzo
- Stockport NHS Foundation Trust, Stockport, UK
| | | | - J Roberts
- Salford Royal NHS Foundation Trust, Salford, UK
| | - J E Scullion
- University Hospitals of Leicester, Leicester, UK
| | - D Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospital Trust, Manchester, UK,
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Schroeder M, Shah D, Risebrough N, Martin A, Zhang S, Ndirangu K, Briggs A, Ismaila AS. Cost-effectiveness analysis of a single-inhaler triple therapy for patients with advanced chronic obstructive pulmonary disease (COPD) using the FULFIL trial: A UK perspective. RESPIRATORY MEDICINE: X 2019. [DOI: 10.1016/j.yrmex.2019.100008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Cost-effectiveness of umeclidinium as add-on to ICS/LABA therapy in COPD: A UK perspective. Respir Med 2018; 145:130-137. [DOI: 10.1016/j.rmed.2018.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 09/17/2018] [Accepted: 10/22/2018] [Indexed: 11/18/2022]
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Parri G, Nieri D, Roggi MA, Vagaggini B, Celi A, Paggiaro P. Fluticasone furoate, umeclidinium bromide, and vilanterol as a combination therapy for chronic obstructive pulmonary disease. Expert Rev Respir Med 2018; 12:997-1005. [PMID: 30463451 DOI: 10.1080/17476348.2018.1548936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Triple therapy with two bronchodilators (LABA plus LAMA) and an inhaled corticosteroid (ICS) is recommended for patients suffering from severe chronic obstructive pulmonary disease (COPD). Areas covered: All 12-52 week-long studies comparing triple therapy with umeclidinium (UM) added to either fluticasone furoate/vilanterol (FF/VI) or fluticasone propionate/salmeterol (FP/SAL) vs. other comparators in COPD patients of group B or D (2011 GOLD classification) were considered. When UM was added to ICS/LABA with separate devices or within a single device, triple combination was more effective than comparators (usually, ICS/LABA combinations) regarding improvements to pulmonary function, symptoms, quality of life and, in the longer studies, rate of moderate-severe exacerbations. The IMPACT study (a large trial comparing UM/FF/VI with both FF/VI and UM/VI combinations) showed that triple therapy had a greater effect compared to dual therapies in reducing the rate of moderate-severe exacerbations, improving trough FEV1 and improving quality of life. The safety profile was good, without excess cardiovascular effects or pneumonia, however, the presence of comorbidities was frequent. Expert commentary: UM/FF/VI combination represents a good option for severe COPD patients who remain symptomatic and/or with frequent exacerbations despite dual therapies. Once daily administration with a simple and effective device may increase adherence and efficacy of the treatment.
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Affiliation(s)
- Giulia Parri
- a Department of Surgery, Medicine, Molecular Biology and Critical Care , University of Pisa , Pisa , Italy
| | - Dario Nieri
- b Bronchology and bronchial endoscopy unit, Department of medical specialties , S. Maria Annunziata hospital , Bagno a Ripoli (Florence) , Italy
| | - Maria Adelaide Roggi
- a Department of Surgery, Medicine, Molecular Biology and Critical Care , University of Pisa , Pisa , Italy
| | - Barbara Vagaggini
- a Department of Surgery, Medicine, Molecular Biology and Critical Care , University of Pisa , Pisa , Italy
| | - Alessandro Celi
- a Department of Surgery, Medicine, Molecular Biology and Critical Care , University of Pisa , Pisa , Italy
| | - Pierluigi Paggiaro
- a Department of Surgery, Medicine, Molecular Biology and Critical Care , University of Pisa , Pisa , Italy
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Zheng Y, Zhu J, Liu Y, Lai W, Lin C, Qiu K, Wu J, Yao W. Triple therapy in the management of chronic obstructive pulmonary disease: systematic review and meta-analysis. BMJ 2018; 363:k4388. [PMID: 30401700 PMCID: PMC6218838 DOI: 10.1136/bmj.k4388] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the rate of moderate to severe exacerbations between triple therapy and dual therapy or monotherapy in patients with chronic obstructive pulmonary disease (COPD). DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES PubMed, Embase, Cochrane databases, and clinical trial registries searched from inception to April 2018. ELIGIBILITY CRITERIA Randomised controlled trials comparing triple therapy with dual therapy or monotherapy in patients with COPD were eligible. Efficacy and safety outcomes of interest were also available. DATA EXTRACTION AND SYNTHESIS Data were collected independently. Meta-analyses were conducted to calculate rate ratios, hazard ratios, risk ratios, and mean differences with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations assessment, development, and evaluation). RESULTS 21 trials (19 publications) were included. Triple therapy consisted of a long acting muscarinic antagonist (LAMA), long acting β agonist (LABA), and inhaled corticosteroid (ICS). Triple therapy was associated with a significantly reduced rate of moderate or severe exacerbations compared with LAMA monotherapy (rate ratio 0.71, 95% confidence interval 0.60 to 0.85), LAMA and LABA (0.78, 0.70 to 0.88), and ICS and LABA (0.77, 0.66 to 0.91). Trough forced expiratory volume in 1 second (FEV1) and quality of life were favourable with triple therapy. The overall safety profile of triple therapy is reassuring, but pneumonia was significantly higher with triple therapy than with dual therapy of LAMA and LABA (relative risk 1.53, 95% confidence interval 1.25 to 1.87). CONCLUSIONS Use of triple therapy resulted in a lower rate of moderate or severe exacerbations of COPD, better lung function, and better health related quality of life than dual therapy or monotherapy in patients with advanced COPD. STUDY REGISTRATION Prospero CRD42018077033.
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Affiliation(s)
- Yayuan Zheng
- Laboratory of Physiological Sciences and Department of Pharmacy of the Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang, China
| | - Jianhong Zhu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuyu Liu
- Department of Pharmacology, Guangdong Medical University, Zhanjiang, China
| | - Weiguang Lai
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
| | - Chunyu Lin
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
| | - Kaifen Qiu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junyan Wu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Weimin Yao
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
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Kerwin EM, Tosiello R, Price B, Sanjar S, Goodin T. Effect of background long-acting beta 2-agonist therapy on the efficacy and safety of a novel, nebulized glycopyrrolate in subjects with moderate-to-very-severe COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:2917-2929. [PMID: 30275690 PMCID: PMC6157543 DOI: 10.2147/copd.s172408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Phase III studies demonstrated efficacy and safety of nebulized glycopyrrolate inhalation solution (GLY) in subjects with COPD. Secondary analyses were performed to examine the effect of background long-acting beta2-agonist (LABA) use on the efficacy and safety of nebulized GLY. Methods In two 12-week placebo-controlled studies (GOLDEN 3 and GOLDEN 4) and one 48-week, open-label active-controlled study (GOLDEN 5), a total of 2,379 subjects were stratified by background LABA use (LABA-yes: n=861; LABA-no: n=1,518) and randomized to placebo vs GLY 25 or 50 µg twice daily, or GLY 50 µg twice daily vs tiotropium (TIO) 18 µg once daily. Lung function, patient-reported outcomes, exacerbations, and safety were assessed. Results Compared with placebo, pooled data from the 12-week studies showed significant improvements from baseline with GLY 25 and 50 µg across LABA subgroups in trough FEV1 (LABA-yes: 0.101 and 0.110 L; LABA-no: 0.092 and 0.101 L, respectively; P<0.001) and St George’s Respiratory Questionnaire total score (SGRQ; LABA-yes: −2.957 and −3.888; LABA-no: −3.301 and −2.073, respectively; P<0.05). Incidence of treatment-emergent adverse events (TEAEs) was similar in LABA subgroups, and lower in GLY 25 µg vs placebo. In the 48-week active-controlled study, GLY and TIO both showed improvement from baseline across LABA subgroups in FEV1 (LABA-yes: 0.106 and 0.092 L; LABA-no: 0.096 and 0.096 L, respectively) and in SGRQ total score (LABA-yes: −5.190 and −3.094; LABA-no: −4.368 and −4.821, respectively). Incidence of TEAEs was similar between GLY and TIO, and across LABA subgroups. Exacerbation rates were similar across treatments and LABA subgroups, and cardiovascular events of special interest were more frequent in the LABA-no subgroup. Nebulized GLY, combined with LABA, did not generate any additional safety signals. Conclusion Nebulized GLY demonstrated efficacy and was well tolerated up to 48 weeks in subjects with COPD with/without background LABA.
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Affiliation(s)
- Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Inc., Medford, OR, USA,
| | | | - Barry Price
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
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Lopez-Campos JL, Navarrete BA, Soriano JB, Soler-Cataluña JJ, González-Moro JMR, Ferrer MEF, Rubio MC. Determinants of medical prescriptions for COPD care: an analysis of the EPOCONSUL clinical audit. Int J Chron Obstruct Pulmon Dis 2018; 13:2279-2288. [PMID: 30100718 PMCID: PMC6067777 DOI: 10.2147/copd.s160842] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose Current COPD management recommendations indicate that pharmacological treatment can be stepped up or down, but there are no recommendations on how to make this adjustment. We aimed to describe pharmacological prescriptions during a routine clinical visit for COPD and study the determinants of changing therapy. Methods EPOCONSUL is a Spanish nationwide observational cross-sectional clinical audit with prospective case recruitment including 4,508 COPD patients from outpatient respiratory clinics for a period of 12 months (May 2014–May 2015). Prescription patterns were examined in 4,448 cases and changes analyzed in stepwise backward, binomial, multivariate, logistic regression models. Results Patterns of prescription of inhaled therapy groups were no treatment prescribed, 124 (2.8%) cases; one or two long-acting bronchodilators (LABDs) alone, 1,502 (34.6%) cases; LABD with inhaled corticosteroids (ICSs), 389 (8.6%) cases; and triple therapy cases, 2,428 (53.9%) cases. Incorrect prescriptions of inhaled therapies were observed in 261 (5.9%) cases. After the clinical visit was audited, 3,494 (77.5%) cases did not modify their therapeutic prescription, 307 (6.8%) cases had a step up, 238 (5.3%) cases had a change for a similar scheme, 182 (4.1%) cases had a step down, and 227 (5.1%) cases had other nonspecified change. Stepping-up strategies were associated with clinical presentation (chronic bronchitis, asthma-like symptoms, and exacerbations), a positive bronchodilator test, and specific inhaled medication groups. Stepping down was associated with lung function impairment, ICS containing regimens, and nonexacerbator phenotype. Conclusion The EPOCONSUL study shows a comprehensive evaluation of pharmacological treatments in COPD care, highlighting strengths and weaknesses, to help us understand how physicians use available drugs.
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Affiliation(s)
- Jose Luis Lopez-Campos
- Medical-Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain, .,CIBER of Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain,
| | | | - Joan B Soriano
- Research Institute, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | | | | | - Manuel E Fuentes Ferrer
- Department of Medicine, Faculty of Medicine, University Complutense of Madrid, Madrid, Spain.,Research Unit, Instituto de Investigación del Hospital Clínico San Carlos, Madrid, Spain.,Clinical Management Unit, Preventive Medicine and Research Institute of Hospital Clínico San Carlos, Madrid, Spain
| | - Myriam Calle Rubio
- Department of Medicine, Faculty of Medicine, University Complutense of Madrid, Madrid, Spain.,Research Unit, Instituto de Investigación del Hospital Clínico San Carlos, Madrid, Spain.,Pneumology Department, Hospital Clínico San Carlos, Madrid, Spain
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Balkissoon R. Impact of the IMPACT Trial. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2018; 5:221-227. [PMID: 30584585 PMCID: PMC6296790 DOI: 10.15326/jcopdf.5.3.2018.0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Huang Y, Li L, Li X, Fan S, Zhuang P, Zhang Y. Ginseng Compatibility Environment Attenuates Toxicity and Keeps Efficacy in Cor Pulmonale Treated by Fuzi Beimu Incompatibility Through the Coordinated Crosstalk of PKA and Epac Signaling Pathways. Front Pharmacol 2018; 9:634. [PMID: 29962951 PMCID: PMC6013823 DOI: 10.3389/fphar.2018.00634] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/29/2018] [Indexed: 12/24/2022] Open
Abstract
Cor pulmonale is characterized by severe right ventricular dysfunction caused by lung disease, particularly chronic obstructive pulmonary disease, which can lead to pulmonary hypertension. Our previous study has demonstrated that Fuzi and Beimu compatibility (FBC), a traditional TCM compatibility taboo, improves lung function in early-stage of pulmonary hypertension through the synergistic action of β-ARs signals. However, FBC increases cardiotoxicity with prolonged treatment and disease progression. Considering that the compatibility environment influences the exertion of the medicine, we selected ginseng for coordinating the compatibility environment to improve the security and extend the therapeutic time window of FBC. Monocrotaline-induced cor pulmonale rats were treated with FBC, ginseng, or ginseng combined with FBC (G/FBC). Then, the pulmonary and cardiac functions of the rats were examined to evaluate the toxicity and efficacy of the treatments. The crosstalk between PKA and Epac pathways was also studied. Results showed that G/FBC ameliorated lung function similar to or even better than FBC treatment did. Furthermore, G/FBC treatment attenuated FBC-induced cardiotoxicity, which significantly restored cardiac dysfunction and clearly decreased myocardial enzymes and apoptosis. The βAR-Gs-PKA/CaMKII pathway was inhibited and the Epac1/ERK1/2 axis was activated in G/FBC group. These findings indicate that ginseng compatibility environment could improve pulmonary function and attenuate cardiotoxicity in cor pulmonale via the coordinated crosstalk of PKA and Epac pathways, implying that ginseng could be used to prevent detrimental cardiotoxicity in cor pulmonale treatment.
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Affiliation(s)
- Yingying Huang
- Chinese Materia Medica College, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Lili Li
- Chinese Materia Medica College, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiaojin Li
- Chinese Materia Medica College, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Simiao Fan
- Chinese Materia Medica College, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Pengwei Zhuang
- Chinese Materia Medica College, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yanjun Zhang
- Chinese Materia Medica College, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Fluticasone furoate/umeclidinium/vilanterol dry-powder inhaler in COPD: a profile of its use in the EU. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0513-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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41
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Huang YY, Li XJ, Liu KX, Zhuang PW, Zhang YJ. Toxicity-efficacy converting of ginseng combined with Fuzi Banxia incompatibility in heart failure stage of cor pulmonale. CHINESE HERBAL MEDICINES 2018. [DOI: 10.1016/j.chmed.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Molino A, Calabrese G, Maniscalco M. Patient considerations in the treatment of COPD: focus on the new combination inhaler fluticasone furoate/umeclidinium/vilanterol. Patient Prefer Adherence 2018; 12:993-1001. [PMID: 29922045 PMCID: PMC5997126 DOI: 10.2147/ppa.s152179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The pharmacological treatment for stable COPD is based on the use of inhaled bronchodilators (long-acting muscarinic receptor antagonists and long-acting beta-2 adrenoceptor agonists) and inhaled corticosteroids. The use of triple inhaled therapy is recommended to selected patients with COPD. Among the various inhaler combinations in triple therapy, a new combination by fluticasone furoate, umeclidinium, and vilanterol is available for COPD patients. Recently, a large clinical trial using this combination has been published, resulting in a reduction in exacerbation rate in COPD patients. Furthermore, this combination has demonstrated efficacy and safety, with a single administration a day, through a dry powder inhalator device, which has shown a good adherence and is a preference of the patient. This review focuses on the main characteristics of this inhaler combination evaluating the main clinical effects, the patients' adherence, and the safety.
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Affiliation(s)
- Antonio Molino
- Division of Pneumology, Department of Respiratory Diseases, University of Naples Federico II, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Giovanna Calabrese
- Division of Pneumology, Department of Respiratory Diseases, University of Naples Federico II, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Mauro Maniscalco
- Pulmonary Rehabilitation Division, ICS Maugeri SpA SB, Institute of Telese Terme, Telese Terme, Benevento, Italy
- Correspondence: Mauro Maniscalco, Via Bagni Vecchi 1, 82037 Telese Terme, Benevento, Italy, Tel/fax +39 8 2490 9350, Email
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