Long-acting inhaled beta 2-agonists for stable COPD

Oral Chinese herbal medicine for improvement of quality of life in patients with stable chronic obstructive pulmonary disease: a systematic review

PURPOSE

This study evaluates published clinical trials of Chinese herbal medicine (CHM) for chronic obstructive pulmonary disease (COPD) that employ a health-related quality of life (HRQoL) outcome measure.

METHODS

Searches were conducted in April 2011 on MEDLINE, Embase, the Cochrane Controlled Trials Register, CINAHL, Scopus, and Chinese databases (CNKI, CQVIP, WANFANG). Randomized controlled trials involving oral administration of CHM formulae or single herb, with or without blinding, compared to placebo, no treatment, routine pharmacotherapy control, or CHM plus routine pharmacotherapy versus routine pharmacotherapy, with a HRQoL questionnaire as an outcome measure were identified. The methodological quality was assessed using the Cochrane risk of bias assessment.

RESULTS

A total of 27 studies involving 1966 patients were identified. St. George Respiratory Questionnaire (SGRQ) or Cai's QoLQ were used in 13 and 14 studies, respectively. Assessment of the Cochrane risk of bias revealed adequate sequence of generation in 10 studies and adequate allocation concealment in 1 study; double blinding was not described adequately in any studies. Seventeen (17) studies addressed incomplete outcome data, and 17 studies were free of selective reporting. The main results of meta-analysis showed improvement of total HRQoL scores (SGRQ and Cai's QoLQ) when CHM was compared to no treatment (-6.07 [-9.21, -2.93] and -0.20 [-32, -0.07], respectively) and for CHM plus routine pharmacotherapy versus routine pharmacotherapy (-5.15 [-7.26, -3.05]) and (-0.25 [-0.37, -0.13]).

CONCLUSIONS

While the results of CHM on HRQoL for stable COPD sufferers were promising, they need to be interpreted with caution due to methodological problems, which should be addressed in future trials.

Clinical Safety of Long-Acting β2-Agonist and Inhaled Corticosteroid Combination Therapy in COPD

Long-acting beta2-agonist (LABA) and inhaled corticosteroid (ICS) combination therapy is recommended by international treatment guidelines for COPD. The current literature concerning the safety of LABAs and ICS, both as monotherapies and in combination, in patients with COPD is reviewed. Bronchodilators such as LABAs are key treatments for COPD due to their effects on bronchial smooth muscle and airflow limitation. LABAs are well-tolerated in patients with COPD, with a low incidence of reported adverse events (AEs). Most AEs associated with LABA use are due to systemic exposure and include muscle tremor and cardiac effects. Placebo-controlled studies in patients with COPD demonstrate that there is no increase in risk of cardiac AEs with LABA therapy. ICS therapy targets airway inflammation in COPD, and is associated with a reduction in the frequency of COPD exacerbations, and improvements in symptoms, lung function and health status. Localized effects such as oropharyngeal irritation are common with ICS, but are not considered to be serious. Potential ocular effects with ICS therapy in patients with COPD have been identified and require further investigation. Rare, but more serious AEs related to ICS use are the effects on bone and the suppression of endogenous cortisol production; however, the clinical relevance of these effects is unclear. Clinical data indicate that LABA/ICS combination therapy is more effective in COPD than either agent used alone and is not associated with any additional AEs.

Formoterol fumarate inhalation solution (Perforomist) for COPD

Formoterol fumarate is an effective treatment for chronic obstructive pulmonary disease (COPD) patients with moderate or greater severity of airflow obstruction. Published studies indicate that formoterol has a rapid onset of bronchodilation, which may enhance compliance, and sustained bronchodilation over 12 h, which produces a cumulative effect when inhaled twice daily. With long-term use, formoterol fumarate increases trough forced expiratory volume in 1 s and improves measures of hyperinflation, which correlate with relief of symptoms and a decreased need for additional short-acting bronchodilators as rescue treatment. The combination of formoterol with anticholinergic bronchodilators, especially the long-acting anticholinergic tiotropium, appears to further improve bronchodilation, decrease hyperinflation, improve symptoms and decrease the need for rescue therapy, compared with either agent alone. The availability of formoterol fumarate inhalation solution (Perforomist) for treatment of COPD now extends these benefits to patients who prefer nebulizer therapy and/or cannot use metered-dose or dry-powder inhalers effectively.

Disease modification in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease in which patients experience a progressive decline in lung function, worsening exercise capacity, and frequent exacerbations. Based on clinical evidence, the progression of COPD could be modified by focus on earlier diagnosis; risk reduction through smoking cessation; symptom reduction with pharmacotherapy, improving health-related quality of life, and pulmonary rehabilitation; and decreasing complications by reducing exacerbations. Smoking cessation has been shown to slow lung function decline and reduce mortality, including deaths due to cardiovascular disease, lung cancer, and other respiratory disease (including COPD).

Inhaled therapy for stable chronic obstructive pulmonary disease

Bronchodilators (anticholinergic drugs and beta2-agonist drugs) represent the mainstay of chronic obstructive pulmonary disease treatment and can be combined with inhaled corticosteroids for greater efficacy. This review examines the role of short- and long-acting cholinergic drugs, together with that of short- and long-acting beta2-agonist drugs. A brief analysis of the long-term use of corticosteroids in chronic obstructive pulmonary disease is made, with a review of the safety and possible side effects. Combination therapy is more frequently used due to its practicality and capacity to enhance compliance. The main studies on treatment combinations are also analyzed in this paper.

Clinical course of chronic obstructive pulmonary disease: review of therapeutic interventions

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease in which patients experience a progressive decline in lung function. Based on clinical evidence, the management of COPD should focus on (1) earlier diagnosis; (2) risk reduction through smoking cessation, decreased exposure to inhaled irritants, and immunization against respiratory pathogens; (3) symptom reduction with pharmacotherapy and pulmonary rehabilitation; (4) decreasing complications by reducing exacerbations and improving pulmonary function; and (5) improving health-related quality of life (HRQOL). Smoking cessation has been shown to slow lung function decline and to reduce mortality--including deaths due to lung cancer, other respiratory disease (including COPD), and cardiovascular disease. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the American Thoracic Society and European Respiratory Society (ATS/ERS) guidelines advocate interventions according to the severity of COPD and recommend initiation of maintenance long-acting bronchodilator therapy in patients with moderate disease. However, recent evidence from a post hoc analysis of randomized controlled trials of tiotropium suggests that initiation of long-acting bronchodilator therapy at earlier stages of disease may also provide improvements in lung function and HRQOL. The results of ongoing long-term studies may soon provide evidence that in addition to relieving symptoms and improving patient HRQOL, specific pharmacologic therapies may also alter the clinical course of COPD.

Drugs in clinical development for chronic obstructive pulmonary disease

Many drugs may be potentially useful in the treatment of chronic obstructive pulmonary disease (COPD), but relatively few become available for human use due to lack of safety, lack of efficacy, or both. This is an inherent risk in the drug development process, which coupled with the limited understanding of the molecular pathogenesis of COPD, has produced a trend toward improving existing compounds rather than to develop new compounds. This review focuses on improved existing compounds and newly discovered compounds that are in clinical trials, but not yet marketed. The improved existing compounds include: isomers of the long-acting bronchodilators, once-daily beta2-adrenoceptor agonists, anticholinergics and corticosteroids. The pool of novel compounds is in constant fluctuation and comprises anti-inflammatory drugs, antioxidants, leukotriene modifiers and a number of compounds aimed at treating different aspects of COPD such as pulmonary hypertension and hypophosphatemia.

COPD, a multicomponent disease: implications for management

Chronic obstructive pulmonary disease (COPD) is a multicomponent disease. These components affect both the lungs and organs outside the lungs (the so-called systemic effects of COPD) and can be of either a structural (including airway remodelling, emphysema, skeletal muscle wasting) or functional nature (inflammation, apoptosis, senescence). Further, these components are interdependent in a closely linked 'vicious cycle'. Accordingly, optimal therapies should therefore aim to address more than one of these components to break such a cycle. This needs to be considered not only in the development of future treatments but also in the current clinical management of patients with COPD. In this paper, evidence that supports the concept that COPD is a multicomponent disease is presented. The effects of currently available therapeutic options, including long-acting anticholinergics and long-acting beta2-agonist/inhaled corticosteroid combination therapies, upon each of these components is reviewed. In addition, potential new avenues for drug development and improved patient care are highlighted. By developing a better understanding of how different therapies impact upon the 'vicious cycle' of COPD, treatment regimens can be optimised to provide the greatest benefits to patients.

Acute Exacerbation of COPD

Nurses in acute care settings play a vital role in caring for individuals during an acute exacerbation of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. In addressing this health concern, the Global Initiative for Chronic Obstructive Lung Disease Report summarized the goals for COPD management and recommended treatment supported by current data and research. It is imperative that our clinical nursing practice is based upon research-supported interventions: use of appropriate medications, monitoring acid-base status, administering controlled oxygen therapy, assessing the need for mechanical ventilation, and close monitoring of comorbid illnesses. Health promotion includes patient and family education on early recognition of symptoms, smoking cessation strategies, and participation in pulmonary rehabilitation that can reduce long-term morbidity from this chronic disease.

Long acting beta2 agonists for stable chronic obstructive pulmonary disease with poor reversibility: a systematic review of randomised controlled trials

Background

The long acting β2-agonists, salmeterol and formoterol, have been recommended, by some, as first line treatment of stable chronic obstructive pulmonary disease (COPD). We reviewed evidence of efficacy and safety when compared with placebo or anticholinergic agents in patients with poorly reversible COPD.

Methods

After searching MEDLINE, EMBASE, HealthSTAR, BIOSIS Previews, PASCAL, ToxFile, SciSearch, the Cochrane Library, and PubMed, as well as Web sites, selected journals, reference lists, and contacting drug manufacturers, two reviewers independently screened reports of randomised controlled trials of parallel or crossover design lasting four weeks or longer and including patients with a forced expiratory volume in one second (FEV1) ≤ 75% of predicted, a ratio of FEV1 to forced vital capacity (FVC) ≤ 88% of predicted, and < 15% improvement from baseline FEV1 after a dose of a β2 agonist. We included trials comparing salmeterol or formoterol with placebo or with ipratropium bromide and reporting one of these outcomes: lung function; exercise capacity; quality of life scores; dyspnea; exacerbations; rescue inhaler use; incidence of tachycardia, hypokalemia, or dry mouth. Two reviewers assessed the quality of included reports using the Jadad scale and allocation concealment, and abstracted data.

Results

Twelve trials satisfied our inclusion criteria; eight were high quality (Jadad score >2) and four were low quality (≤ 2). The adequacy of allocation concealment was unclear in all of them. We did not perform a meta-analysis due to differences in trial design and how outcomes were reported.

Two trials comparing salmeterol with ipratropium did not detect differences; one trial comparing formoterol and ipratropium described greater improvement with formoterol in morning PEFR (15.3 versus 7.1 l/min, p = 0.040).

Of twelve trials comparing long acting β2 agonists with placebo, six reported no improvement in exercise capacity, eleven reported improvements in FEV1 lung function (one reported no improvement), six reported less rescue inhaler usage (one reported no difference) and five reported improved dyspnea scores (two reported no improvement). Differences in quality of life were detected in one salmeterol trial ; however, two salmeterol, and one formoterol trial reported no differences. Adverse effects of interest were not reported.

Conclusion

In terms of clinical outcomes and safety, we could not find convincing evidence that salmeterol and formoterol have demonstrated advantages to ipratropium, a less expensive drug, for patients with stable COPD and poor reversibility. Compared to placebo, we found evidence of reduced rescue inhaler usage and improved spirometric outcomes without a significant impact on quality of life or exercise capacity.