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Klitgaard A, Ibsen R, Lykkegaard J, Hilberg O, Løkke A. Inhaled corticosteroid treatment and pneumonia in patients with chronic obstructive pulmonary disease - nationwide development from 1998 to 2018. Eur Clin Respir J 2024; 11:2359768. [PMID: 38817947 PMCID: PMC11138226 DOI: 10.1080/20018525.2024.2359768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024] Open
Abstract
Background A decreasing use of inhaled corticosteroids (ICS) in patients with a hospital-registered diagnosis of chronic obstructive pulmonary disease (COPD) has recently been documented in Denmark. ICS treatment is not recommended in patients with high pneumonia risk, and we aimed to assess the development of ICS treatment in relation to pneumonia occurrence. Methods Annual nationwide register-based cross-sectional studies from 1998 to 2018 including all patients ≥40 years of age with a hospital-registered ICD-10 diagnosis of COPD on the 31st of December each year. We calculated the annual proportion of patients with at least one outpatient pneumonia (redeemed prescription of relevant antibiotics) or pneumonia hospitalization (hospitalization or ER visit), and stratified by ICS dose (No ICS, low dose, medium dose, or high dose). Results The study population increased from 35,656 patients in 1998 to 99,057 patients in 2018. The annual proportion of patients experiencing a pneumonia decreased from 69.4% to 55.2%. The proportion of patients with at least one outpatient pneumonia, but no hospitalization, decreased (59.2% to 46.2%). The overall proportion of patients with at least one pneumonia hospitalization remained unchanged (10.2% to 9.0%), but this proportion increased in patients in high dose ICS (9.9% to 14.6%). The overall proportion of patients in high dose treatment decreased (12.7% to 5.7%), but not in patients with pneumonia hospitalization (16.5% to 15.1). Conclusions Our study demonstrates a nationwide decrease from 1998 to 2018 in the proportion of patients who redeemed a prescription for antibiotics used mainly for respiratory tract infections, which may reflect a decrease in the number of outpatient pneumonias. This decrease was largely caused by an increase in the number of patients without pneumonia. No differences over time were seen regarding hospitalization-requiring pneumonia. High dose ICS treatment was unchanged in patients with hospitalization-requiring pneumonia.
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Affiliation(s)
- Allan Klitgaard
- Department of Internal Medicine Vejle, Lillebaelt Hospital, Vejle, Denmark
| | | | - Jesper Lykkegaard
- Research Unit of General Practice, Syddansk Universitet- Campus Esbjerg, Esbjerg, Denmark
| | - Ole Hilberg
- Department of Regional Health Research, Syddansk Universitet, Odense, Denmark
| | - Anders Løkke
- Department of Regional Health Research, Syddansk Universitet, Odense, Denmark
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2
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Schroeder MN, Sens HM, Shah SK. De-Prescribing Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease: A Narrative Review. J Pharm Pract 2024; 37:478-484. [PMID: 36458847 DOI: 10.1177/08971900221144127] [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] [Indexed: 02/16/2024]
Abstract
Objective: Combination therapy, including inhaled corticosteroids (ICS), is often prescribed as initial treatment for Chronic Obstructive Pulmonary Disease (COPD) despite limited evidence that ICS therapy is beneficial. Prescribing rates exceed the estimated number of candidates diagnosed with COPD who are eligible for ICS treatment per guideline-directed therapy. Therefore, some patients would benefit from ICS withdrawal due to potentially inappropriate prescribing. This review aims to highlight evidence evaluating ICS withdrawal approaches in COPD. Methods: A comprehensive literature review was performed between June 2021 and March 2022 with assistance from a reference librarian. Sources of literature review include PubMed and Embase. The authors selected randomized controlled trials and articles evaluating ICS withdrawal approaches in patients with COPD. Three clinical trials and one post-hoc analysis are discussed in this review. Pertinent safety, efficacy, and statistical and clinical outcomes are summarized. Conclusions: The most appropriate approach to de-prescribe ICS maintenance therapy in COPD without clear indication remains uncertain. Pharmacists can play a role in optimizing clinical outcomes by analyzing ICS use in practice and identifying potential candidates for ICS withdrawal. The withdrawal protocols discussed in this review offer options for clinicians to help guide therapy decisions.
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Affiliation(s)
- Michelle N Schroeder
- Department of Pharmacy Practice, University of Toledo College of Pharmacy & Pharmaceutical Sciences, Toledo, OH, USA
| | - Hailee M Sens
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Shaina K Shah
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
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3
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Melani AS, Croce S, Fabbri G, Messina M, Bargagli E. Inhaled Corticosteroids in Subjects with Chronic Obstructive Pulmonary Disease: An Old, Unfinished History. Biomolecules 2024; 14:195. [PMID: 38397432 PMCID: PMC10887366 DOI: 10.3390/biom14020195] [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: 12/11/2023] [Revised: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the major causes of disability and death. Maintenance use of inhaled bronchodilator(s) is the cornerstone of COPD pharmacological therapy, but inhaled corticosteroids (ICSs) are also commonly used. This narrative paper reviews the role of ICSs as maintenance treatment in combination with bronchodilators, usually in a single inhaler, in stable COPD subjects. The guidelines strongly recommend the addition of an ICS in COPD subjects with a history of concomitant asthma or as a step-up on the top of dual bronchodilators in the presence of hospitalization for exacerbation or at least two moderate exacerbations per year plus high blood eosinophil counts (≥300/mcl). This indication would only involve some COPD subjects. In contrast, in real life, triple inhaled therapy is largely used in COPD, independently of symptoms and in the presence of exacerbations. We will discuss the results of recent randomized controlled trials that found reduced all-cause mortality with triple inhaled therapy compared with dual inhaled long-acting bronchodilator therapy. ICS use is frequently associated with common local adverse events, such as dysphonia, oral candidiasis, and increased risk of pneumonia. Other side effects, such as systemic toxicity and unfavorable changes in the lung microbiome, are suspected mainly at higher doses of ICS in elderly COPD subjects with comorbidities, even if not fully demonstrated. We conclude that, contrary to real life, the use of ICS should be carefully evaluated in stable COPD patients.
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Affiliation(s)
- Andrea S. Melani
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (S.C.); (G.F.); (M.M.); (E.B.)
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4
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Vauterin D, Van Vaerenbergh F, Vanoverschelde A, Quint JK, Verhamme K, Lahousse L. Methods to assess COPD medications adherence in healthcare databases: a systematic review. Eur Respir Rev 2023; 32:230103. [PMID: 37758274 PMCID: PMC10523153 DOI: 10.1183/16000617.0103-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/20/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The Global Initiative for Chronic Obstructive Lung Disease 2023 report recommends medication adherence assessment in COPD as an action item. Healthcare databases provide opportunities for objective assessments; however, multiple methods exist. We aimed to systematically review the literature to describe existing methods to assess adherence in COPD in healthcare databases and to evaluate the reporting of influencing variables. METHOD We searched MEDLINE, Web of Science and Embase for peer-reviewed articles evaluating adherence to COPD medication in electronic databases, written in English, published up to 11 October 2022 (PROSPERO identifier CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. Methods to assess initiation (dispensing of medication after prescribing), implementation (extent of use over a specific time period) and/or persistence (time from initiation to discontinuation) were listed descriptively. Each included study was evaluated for reporting variables with an impact on adherence assessment: inpatient stays, drug substitution, dose switching and early refills. RESULTS 160 studies were included, of which four assessed initiation, 135 implementation and 45 persistence. Overall, one method was used to measure initiation, 43 methods for implementation and seven methods for persistence. Most of the included implementation studies reported medication possession ratio, proportion of days covered and/or an alteration of these methods. Only 11% of the included studies mentioned the potential impact of the evaluated variables. CONCLUSION Variations in adherence assessment methods are common. Attention to transparency, reporting of variables with an impact on adherence assessment and rationale for choosing an adherence cut-off or treatment gap is recommended.
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Affiliation(s)
- Delphine Vauterin
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Frauke Van Vaerenbergh
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Anna Vanoverschelde
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jennifer K Quint
- School of Public Health and National Heart and Lung Institute, Imperial College London, London, UK
| | - Katia Verhamme
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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5
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Elsouri KN, Arboleda V, Basbous L, Heiser S, Collins DP, Ragusa P, Baxter C, Cabrera D, Akhand T, Stermer E, Sharma K, Seguro C, Hardigan P, Kesselman M, Beckler MD. Glucocorticoid use in rheumatoid arthritis patients and the onset of pneumonia: a systematic review and meta-analysis. J Osteopath Med 2023; 123:179-186. [PMID: 36691851 DOI: 10.1515/jom-2022-0177] [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: 08/21/2022] [Accepted: 11/29/2022] [Indexed: 01/25/2023]
Abstract
CONTEXT Rheumatoid arthritis (RA) is a systemic autoimmune disease that commonly affects joints. Although many treatment options exist, the most common, disease-modifying antirheumatic drugs (DMARDs), have been associated with pulmonary infections. These types of infections (specifically pneumonia) can be detrimental to RA patients. This leads providers to utilize other treatment modalities such as glucocorticoids (GCs). GCs are commonly utilized to treat RA; however, the role of GCs in the onset of pneumonia in RA patients is not fully understood. OBJECTIVES The goal of this study was to systematically review and statistically analyze pooled data documenting pneumonia as an adverse event in RA patients on DMARDs as a monotherapy vs RA patients on DMARDs and GCs as combination therapy utilizing the Population, Intervention, Comparison, and Outcomes (PICO) framework. METHODS On August 1, 2021, a search was conducted and completed on six databases: Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, International Pharmaceutical Abstracts (IPA), and ClinicalTrials.gov. A total of 12 researchers were involved with the search and screening of articles (K.E., P.R.; V.A., D.P.C.; C.B., D.C.; T.A., E.S.; S.H., L.B.; K.S., C.S.). Search terms were identified utilizing Medical Subject Headings (MeSH) and Emtree and included "glucocorticoids," "rheumatoid arthritis," "pneumonia," and "respiratory tract infections," Inclusion criteria included human subjects over the age of 18 with seropositive RA, on a combination of GC (prednisone, methylprednisolone, or prednisolone) with DMARD (methotrexate [MTX], hydroxychloroquine [HCQ], or sulfasalazine [SSZ]) and developed pneumonia of bacterial, viral, or fungal origin. The control groups were on a DMARD monotherapy regimen. Articles were excluded if they were not in English, had less than 20 participants, were case reports or literature reviews, included animal subjects, and did not adhere to the established PICO framework. Five teams of two researchers individually sorted through abstracts of articles based on the inclusion and exclusion criteria. The same teams individually sorted through full-text articles of selected abstracts based on the same criteria. Conflicts between each team were resolved by a separate researcher. Odds ratios were utilized to quantify the effect sizes of combined studies from a random effects model. Chi-square tests and I2 statistics were utilized to analyze heterogeneity. RESULTS A total of 3360 articles were identified from all databases, and 416 duplicate articles were removed. Thus, a total of 2944 articles abstracts were screened, of which 2819 articles either did not meet the inclusion criteria or did meet the exclusion criteria. A total of 125 articles were retrieved and assessed for full-text eligibility, of which only three observational articles were included for meta-analysis. Statistical results revealed that patients treated with DMARDs monotherapy are 95% (95% CI: 0.65-0.99) less likely to develop pneumonia compared to patients treated with a DMARD and GCs (p=0.002). CONCLUSIONS Our data suggest that RA patients have a higher probability of developing pneumonia on combination therapy with GCs, compared to monotherapy with DMARDs. To our knowledge, our findings are the first to systematically review and statistically evaluate the relationship between the use of GCs and show an increased chance of developing pneumonia.
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Affiliation(s)
- Kawther N Elsouri
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Vania Arboleda
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | | | - Samantha Heiser
- William Carey University College of Osteopathic Medicine, Hattiesburg, MS, USA
| | - Dylon P Collins
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Philip Ragusa
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Courney Baxter
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Dominick Cabrera
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Tanisha Akhand
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Evan Stermer
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Kiran Sharma
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Charmaine Seguro
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Patrick Hardigan
- Nova Southeastern University Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Marc Kesselman
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Michelle Demory Beckler
- Nova Southeastern University Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
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Park JW, Hong Y, Rhee CK, Choi HS, Kim K, Yoo KH, Jung KS, Park JH. The Impact of Inhaled Corticosteroids on the Prognosis of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2023; 18:733-743. [PMID: 37159577 PMCID: PMC10163892 DOI: 10.2147/copd.s388367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 04/06/2023] [Indexed: 05/11/2023] Open
Abstract
Background A comprehensive analysis of the effects of inhaled corticosteroids (ICS) on COPD in a real-world setting is required due to safety concerns regarding ICS in COPD. This study aimed to explore the impact of ICS on the prognosis of Asian COPD patients in the real-life world. Methods We examined 978 COPD patients registered in the Korean National Health and Nutrition Examination Survey (KNHANES) database and with their data linked to Health Insurance and Review Assessment (HIRA) data. The outcome measures were ascertained by HIRA from January 1, 2009, to December 31, 2012. This study enrolled two arms; ICS users (N = 85, mean age = 66.7 ± 8.9 years) and non-ICS users (N = 893, mean age = 63.7 ± 9.7 years). Results Compared to the non-ICS users, the ICS users had a higher rate of pneumonia, tuberculosis, and acute exacerbations (P<0.05). Hospitalization due to respiratory causes was also higher among ICS users (P<0.05). Multivariate analysis showed that acute exacerbation was independently associated with the development of pneumonia (P<0.05), whereas ICS therapy had a tendency to be associated with pneumonia. Another multivariate analysis demonstrated that old age, FEV1, ICS therapy, and pneumonia were independently associated with the occurrence of acute exacerbation (P<0.05). The concomitant pneumonia (HR = 3.353, P = 0.004) was independently associated with higher mortality (P<0.05). Conclusion Our data demonstrated that the ICS users had a higher rate of pneumonia and tuberculosis and the concomitant pneumonia was independently associated with higher mortality, highlighting the importance of cautious and targeted administration of ICS in COPD.
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Affiliation(s)
- Ji Won Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, South Korea
| | - Yoonki Hong
- Department of Internal Medicine, Kangwon National University, Chuncheon, South Korea
| | - Chin Kook Rhee
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hye Sook Choi
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, South Korea
| | - Kyungjoo Kim
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kwang Ha Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, South Korea
| | - Ki-Suck Jung
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, South Korea
- Correspondence: Joo Hun Park, Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Worldcup road 164, Suwon, Gyeonggi-do, 16499, South Korea, Tel +82-31-219-5116; +82-10-8379-8299, Fax +82-31-219-5124, Email ;
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7
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Miravitlles M, González-Torralba F, Represas-Represas C, Pomares X, Márquez-Martín E, González C, Amado C, Forné C, Alonso S, Alcázar B, Barrecheguren M, Jurado Mirete JM, Naval E. Pulmonologists' Opinion on the Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Patients in Spain: A Cross-Sectional Survey. Int J Chron Obstruct Pulmon Dis 2022; 17:1577-1587. [PMID: 35855745 PMCID: PMC9288191 DOI: 10.2147/copd.s369118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD. Methods A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal. Results A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction. Conclusion In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain
| | | | | | - Xavier Pomares
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Pneumology Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Eduardo Márquez-Martín
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Medical-Surgical Unit for Respiratory Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Cruz González
- Pneumology Department, Hospital Clínico de Valencia, Valencia, Spain
| | - Carlos Amado
- Pneumology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carles Forné
- Heorfy Consulting, Lleida, Spain.,Basic Medical Sciences Department, University of Lleida, Lleida, Spain
| | - Soledad Alonso
- Pneumology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Bernardino Alcázar
- Pneumology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Elsa Naval
- Pneumology Department, Hospital Universitario de La Ribera, Alzira, Spain
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8
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Shu CC, Wei YF, Chen KH, Chuang S, Wang YH, Wang CY, Wang HC. Inhaled corticosteroids increase risk of nontuberculous mycobacterial lung disease: a nested case control study and meta-analysis. J Infect Dis 2021; 225:627-636. [PMID: 34435631 DOI: 10.1093/infdis/jiab428] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Studies on using inhaled corticosteroids (ICS) and the risk of nontuberculous mycobacterial lung disease (NTM-LD) are limited and have some conflict results. We recruited 1,235 NTM-LD patients and found that the ICS use within 1 year was associated with increased NTM-LD, and the risk increased by elevating ICS dose and cumulative duration. Discontinuation of ICS use for more than 120 days could reduce the risk of NTM-LD to an insignificant level. For NTM species, the development of NTM-LD by ICS was highest for M. kansasii lung disease. The pooled results of the meta-analysis echoed that ICS use might increase risk of NTM-LD with dose response since medium daily ICS dose. In addition, budesonide had a smaller impact on the risk of NTM-LD than other ICS medications. The present study and meta-analysis provided evidence for ICS adjustment including dose, discontinuation effect and medications to possibly reduce the risk of NTM-LD.
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Affiliation(s)
- Chin-Chung Shu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Feng Wei
- Department of Internal Medicine, E-Da Cancer Hospital, Kaohsiung, Taiwan.,School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kuang-Hung Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shulin Chuang
- Department of Medical Research, National Taiwan University Hospital, Taipei, 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
| | - 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
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,National Taiwan University College of Medicine, Taipei, Taiwan
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9
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Miravitlles M, Auladell-Rispau A, Monteagudo M, Vázquez-Niebla JC, Mohammed J, Nuñez A, Urrútia G. Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD. Eur Respir Rev 2021; 30:30/160/210075. [PMID: 34168063 DOI: 10.1183/16000617.0075-2021] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/26/2021] [Indexed: 11/05/2022] Open
Abstract
Inhaled corticosteroids (ICSs) are indicated for the prevention of exacerbations in COPD; however, a significant proportion of patients at low risk of exacerbations are treated with ICSs. We conducted a systematic review including a diversity of types of study designs and safety outcomes with the objective of describing the risk of adverse effects associated with the long-term use of ICSs in patients with COPD.A total of 90 references corresponding to 83 studies were included, including 26 randomised clinical trials (RCTs), 33 cohort studies, and 24 nested case-control (NCC) studies. Analysis of 19 RCTs showed that exposure to ICSs for ≥1 year increased the risk of pneumonia by 41% (risk ratio 1.41, 95% CI 1.23-1.61). Additionally, cohort and NCC studies showed an association between ICSs and risk of tuberculosis and mycobacterial disease. There was a strong association between ICS use and local disorders such as oral candidiasis and dysphonia. The association between ICSs and the risk of diabetes and fractures was less clear and appeared significant only at high doses of ICSs.Since most patients with COPD are elderly and with frequent comorbidities, an adequate risk-benefit balance is crucial for the indication of ICSs.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Both authors contributed equally and are considered first authors
| | - Ariadna Auladell-Rispau
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Both authors contributed equally and are considered first authors
| | - Mònica Monteagudo
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Medicine Dept, Universitat Autònoma de Barcelona (UAB), Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Juan Carlos Vázquez-Niebla
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | | | - Alexa Nuñez
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gerard Urrútia
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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10
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Tsiligianni I, Hoeines KJ, Jensen C, Kocks JWH, Ställberg B, Vicente C, Peché R. Towards Rational Prescription of Common Inhaler Medication in the Multimorbid COPD Patient. Int J Chron Obstruct Pulmon Dis 2021; 16:1315-1327. [PMID: 34012259 PMCID: PMC8127323 DOI: 10.2147/copd.s298345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/31/2021] [Indexed: 11/23/2022] Open
Abstract
COPD is a chronic disease, typically accompanied by multiple comorbid conditions. The need to apply several, and sometimes conflicting, disease-specific treatment guidelines, complicates the management of individual patients. Moreover, national and international recommendations evolve rapidly but provide limited guidance on the integrated approach in the multimorbid patient. Particularly bothersome is the fact that the presence of comorbidities may deteriorate the course of COPD, and inversely COPD may affect the outcome of the comorbid diseases. In addition, some effects of commonly prescribed COPD inhaler medications, including beta2-agonists, long-acting antimuscarinics and especially inhaled corticosteroids, mimic or worsen COPD-related comorbidities. Therefore, the authors combined their perspectives to formulate advice that may help physicians to improve COPD patient care in daily practice when comorbidities are present. Diabetes, atrial fibrillation, osteoporosis/fractures, infections (pneumonia and tuberculosis) and asthma were identified as areas where practicing clinicians should give special attention to the risk-benefit ratio of the inhaled medication. Overall, the presence of multimorbidity in a COPD patient should act as a signal to carefully reconsider the treatment choices.
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Affiliation(s)
| | | | | | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Rudi Peché
- Department of Pneumology, ISPPC, CHU Charleroi, Charleroi, Belgium
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11
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Lodise TP, Sethi S. Response to the Letter to the Editor Regarding "Intraclass Difference in Pneumonia Risk with Fluticasone and Budesonide in COPD: A Systematic Review of Evidence from Direct-Comparison Studies" [Response to Letter]. Int J Chron Obstruct Pulmon Dis 2021; 16:1227-1229. [PMID: 34007165 PMCID: PMC8121281 DOI: 10.2147/copd.s315195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College Pharmacy and Health Sciences, Albany, NY, USA
| | - Sanjay Sethi
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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12
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Magnussen H, Lucas S, Lapperre T, Quint JK, Dandurand RJ, Roche N, Papi A, Price D, Miravitlles M. Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study. Respir Res 2021; 22:25. [PMID: 33478491 PMCID: PMC7818945 DOI: 10.1186/s12931-021-01615-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are indicated for prevention of exacerbations in patients with COPD, but they are frequently overprescribed. ICS withdrawal has been recommended by international guidelines in order to prevent side effects in patients in whom ICS are not indicated. METHOD Observational comparative effectiveness study aimed to evaluate the effect of ICS withdrawal versus continuation of triple therapy (TT) in COPD patients in primary care. Data were obtained from the Optimum Patient Care Research Database (OPCRD) in the UK. RESULTS A total of 1046 patients who withdrew ICS were matched 1:4 by time on TT to 4184 patients who continued with TT. Up to 76.1% of the total population had 0 or 1 exacerbation the previous year. After controlling for confounders, patients who discontinued ICS did not have an increased risk of moderate or severe exacerbations (adjusted HR: 1.04, 95% confidence interval (CI) 0.94-1.15; p = 0.441). However, rates of exacerbations managed in primary care (incidence rate ratio (IRR) 1.33, 95% CI 1.10-1.60; p = 0.003) or in hospital (IRR 1.72, 95% CI 1.03-2.86; p = 0.036) were higher in the cessation group. Unsuccessful ICS withdrawal was significantly and independently associated with more frequent courses of oral corticosteroids the previous year and with a blood eosinophil count ≥ 300 cells/μL. CONCLUSIONS In this primary care population of patients with COPD, composed mostly of infrequent exacerbators, discontinuation of ICS from TT was not associated with an increased risk of exacerbation; however, the subgroup of patients with more frequent courses of oral corticosteroids and high blood eosinophil counts should not be withdrawn from ICS. Trial registration European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (EUPAS30851).
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Affiliation(s)
- Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Member of the German Center of Lung Research, Grosshansdorf, Germany
| | | | - Therese Lapperre
- Department of Respiratory Medicine, Antwerp University Hospital, Edegem, Denmark
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Wilrijk, UK
| | - Jennifer K Quint
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Wilrijk, UK
| | - Ronald J Dandurand
- CIUSSS de L'Ouest-de-L'Île-de-Montréal, Montreal Chest Institute, Meakins-Christie Laboratories, Oscillometry Unit and Centre for Innovative Medicine, McGill University Health Centre and Research Institute, Montreal, QC, Canada
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP-Centre University of Paris, UMR1016, Cochin Institute, Paris, France
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall D'Hebron, Vall D'Hebron Institut de Recerca (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
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13
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Rhee CK. Chronic obstructive pulmonary disease research by using big data. CLINICAL RESPIRATORY JOURNAL 2020; 15:257-263. [PMID: 33207087 DOI: 10.1111/crj.13305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 10/01/2020] [Accepted: 11/13/2020] [Indexed: 11/30/2022]
Abstract
As the information technology develops, large amount of data has been stored. The digitalisation of the health-care system enables researchers to use big data easily. Big data have been utilised for valuable source for chronic obstructive pulmonary disease (COPD) research. Various sources of data are now available including nationwide claim data and primary care database. Recently, web data are also used in COPD research. Each different data source has strengths and weaknesses. Merging different data can overcome the limitation of big data research. Future direction of big data research is to integrate multiple big data.
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Affiliation(s)
- Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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14
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Lodise TP, Li J, Gandhi HN, O’Brien G, Sethi S. Intraclass Difference in Pneumonia Risk with Fluticasone and Budesonide in COPD: A Systematic Review of Evidence from Direct-Comparison Studies. Int J Chron Obstruct Pulmon Dis 2020; 15:2889-2900. [PMID: 33204085 PMCID: PMC7667513 DOI: 10.2147/copd.s269637] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/23/2020] [Indexed: 12/13/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) are widely used and recommended to treat chronic obstructive pulmonary disease (COPD). While generally considered safe, several studies demonstrated an increased risk of pneumonia with the use of ICS in COPD patients. Although all ICS indicated for COPD carry the class labeling warning of increased pneumonia risk, evidence suggests an intraclass difference in the risk of pneumonia between inhaled budesonide and fluticasone. To date, systematic reviews of direct-comparison studies have not been performed to assess if an intraclass difference exists. Research Question This review investigated whether there is an intraclass difference in risk of pneumonia between inhaled fluticasone and budesonide, the 2 most commonly used ICS in COPD. Study Design and Methods A search of the medical literature was conducted in PubMed and Embase for the time period of 01/01/69-05/31/19. The search strategy combined terms that defined the patient/disease type, exposures, outcome, and the study/publication type. Descriptive and comparative statistics reported for fluticasone- and budesonide-containing products in each study, including data for pneumonia event subgroups, were extracted and reported by dose, seriousness, or practice setting. Controlled clinical trials and observational studies meeting the inclusion criteria were assessed for methodologic quality by using the appropriate tool from the list of study quality assessment tools developed by the National Institutes of Health. Results The summary relative risk (RR) ratio across 5 included studies (57,199 patients) was 1.13 (95% CI: 1.09-1.19), representing a 13.5% increased risk of pneumonia among fluticasone users compared to budesonide users. Similarly, summary RR ratio for serious pneumonia implied a 14.4% increased risk of serious pneumonia among fluticasone users compared to budesonide users (pooled RR: 1.14; 95% CI: 1.09-1.20). Interpretation There is likely a clinically important intraclass difference in the risk of pneumonia between fluticasone- and budesonide-containing inhaled medications in COPD.
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Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College Pharmacy and Health Sciences, Albany, NY, USA
| | - Jingyi Li
- Global Medical Affairs, AstraZeneca, Gaithersburg, MD, USA
| | | | - Gerald O’Brien
- US Respiratory Medical, AstraZeneca, Wilmington, DE, USA
| | - Sanjay Sethi
- Department of Medicine, University of Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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15
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Saito Z, Yoshida M, Kojima A, Tamura K, Hasegawa T, Kuwano K. Benefits and Risks of Inhaled Corticosteroid Treatment in Patients with Chronic Obstructive Pulmonary Disease Classified by Blood Eosinophil Counts. Lung 2020; 198:925-931. [PMID: 33068153 DOI: 10.1007/s00408-020-00397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) typically includes neutrophilic airway inflammation and eosinophilic inflammation in some cases. Inhaled corticosteroid (ICS) suppresses eosinophilic inflammation of the airway and reduces acute exacerbation (AE). The present study investigated the relationship between ICS and AE in patients with COPD classified by blood eosinophil counts. METHODS Overall, 244 patients with COPD were retrospectively evaluated between 2014 and 2017 and classified into two groups based on blood eosinophil counts (≥ 300/μL and < 300/μL). These patients were then reclassified into subgroups of those with and without ICS. Differences in the characteristics and incidence of AE and pneumonia with AE in each subgroup were evaluated retrospectively. RESULTS All patients with ICS used 320 μg budesonide twice daily. In the group with blood eosinophil counts ≥ 300/μL, patients with ICS had a significantly lower incidence of AE than those without ICS (P = 0.023). Meanwhile, no significant differences were observed in incidence of AE in the group with blood eosinophil counts < 300/μL. In the group with blood eosinophil counts < 300/μL, patients with ICS had a higher incidence of pneumonia with AE (P = 0.009). Conversely, no significant differences were observed in the group with blood eosinophil counts ≥ 300/μL. CONCLUSIONS ICS significantly reduced AE in COPD patients with blood eosinophil counts ≥ 300/μL. Meanwhile, ICS significantly increased pneumonia rate in patients with blood eosinophil count < 300/μL. Blood eosinophil count may be a useful indicator to identify the benefits and risks of ICS in COPD.
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Affiliation(s)
- Zenya Saito
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan.
| | - Masahiro Yoshida
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Ayako Kojima
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Kentaro Tamura
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Tsukasa Hasegawa
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Kazuyoshi Kuwano
- Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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16
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Lee DDH, Cardinale D, Terakosolphan W, Sornsute A, Radhakrishnan P, Coppel J, Smith CM, Satyanarayana S, Forbes B, O'Callaghan C. Fluticasone Particles Bind to Motile Respiratory Cilia: A Mechanism for Enhanced Lung and Systemic Exposure? J Aerosol Med Pulm Drug Deliv 2020; 34:181-188. [PMID: 32960118 DOI: 10.1089/jamp.2020.1598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Inhaled corticosteroids (ICSs) are the main prophylactic treatment for asthma and are used in other diseases, including chronic pulmonary obstructive disease, yet the interaction of ICS particles with the ciliated epithelium remains unclear. The aim of this study was to investigate the earliest interaction of aerosolized fluticasone propionate (FP) particles with human ciliated respiratory epithelium. Methods: A bespoke system was developed to allow aerosolized FP particles to be delivered to ciliated epithelial cultures by nebulization and from a pressurized metered-dose inhaler (pMDI) through a spacer with interactions observed in real time using high-speed video microscopy. Interaction with nonrespiratory cilia was investigated using steroids on brain ependymal ciliary cultures. The dissolution rate of steroid particles was determined. Results: FP particles delivered by aerosol attached to the tips of rapidly beating cilia. Within 2 hours, 8.7% ± 1.8% (nebulization) and 12.1% ± 2.1% (pMDI through spacer) of ciliated cells had one or more particles attached to motile cilia. These levels decreased to 5.8% ± 1.6% (p = 0.59; nebulization) and 5.3% ± 2.2% (p = 0.14; pMDI through spacer) at 24 hours. Particle attachment did not affect ciliary beat frequency (p > 0.05) but significantly (p < 0.001) reduced ciliary beat amplitude. Steroid particles also attached to the tips of motile ependymal brain cilia and also reduced beat amplitude (24 hours: >2 particles bound p < 0.001). Dissolution of FP particles was slow with only 22.8% ± 1.3% of nebulized and 12.8% ± 0.5% of pMDI-delivered drug dissolving by 24 hours. Conclusions: FP particles adhere to the tips of rapidly moving cilia with significant numbers remaining bound at 24 hours, resisting the shear stress generated by ciliary beating. In vivo, this mechanism may predispose to high local drug concentrations and enhance respiratory and systemic corticosteroid exposure.
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Affiliation(s)
- Dani Do Hyang Lee
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | - Daniela Cardinale
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | | | - Acom Sornsute
- Pharmaceutics, UCL School of Pharmacy, London, United Kingdom
| | - Priya Radhakrishnan
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | - Jonathan Coppel
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | - Claire M Smith
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | | | - Ben Forbes
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
| | - Christopher O'Callaghan
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
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17
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Rogliani P, Ritondo BL, Gabriele M, Cazzola M, Calzetta L. Optimizing de-escalation of inhaled corticosteroids in COPD: a systematic review of real-world findings. Expert Rev Clin Pharmacol 2020; 13:977-990. [DOI: 10.1080/17512433.2020.1817739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Paola Rogliani
- Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | | | - Mariachiara Gabriele
- Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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18
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Abstract
More than one-third of patients with chronic obstructive pulmonary disease (COPD) continue to smoke cigarettes despite knowing they have the disease. This behavior has a negative impact on prognosis and progression, as repeated injury enhances the pathobiological mechanisms responsible for the disease. A combination of counseling plus pharmacotherapy is the most effective cessation treatment of smokers with COPD, and varenicline seems to be the most effective pharmacologic intervention. Preventing exacerbations in patients with COPD is a major goal of treatment, and vaccination against influenza and pneumococcus is an effective preventive strategy to achieve this goal.
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Affiliation(s)
- Maria Montes de Oca
- Servicio de Neumonología, Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Centro Médico de Caracas, Av. Los Erasos, Edf. Anexo B, Piso 4, Consultorio 4B, San Bernardino, Caracas, Venezuela.
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19
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Baron AJ, Flokstra-de Blok BMJ, van Heijst E, Riemersma RA, Sonnenschein-van der Voort AMM, Metting EI, Kocks JWH. Prevalence of Asthma Characteristics in COPD Patients in a Dutch Well-Established Asthma/COPD Service for Primary Care. Int J Chron Obstruct Pulmon Dis 2020; 15:1601-1611. [PMID: 32753860 PMCID: PMC7351624 DOI: 10.2147/copd.s247819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/24/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Primary care COPD guidelines indicate that COPD patients with asthma characteristics should be treated as having asthma. This study aims to describe the prevalence of asthma characteristics in patients with a pulmonologist-confirmed working diagnosis of COPD or ACO. Patients and Methods This retrospective cross-sectional study used real-life data (collected between 2007 and 2017) from a Dutch asthma/COPD-service, a structured web-based system in which pulmonologists support general practitioners in their diagnosis of patients with suspicion of obstructive lung disease. The prevalence of asthma characteristics (history of asthma, atopy, symptoms, and reversibility) and blood eosinophil (Eos) counts were assessed in patients with a working diagnosis of COPD or ACO. Results Of the 14,141 patients, ≥40 years in the dataset, 4475 (31.6%) were diagnosed with asthma, 3532 (25.0%) with COPD, and 1276 (9.0%) with ACO. Asthma characteristics were present in 65.6% (n=1956) of the COPD and 90.9% (n=1059) of the ACO patients. Eos counts of ≥ 300 cells per μL were found in 35.7% (n=924) of the COPD patients and 35.3% (n=341) of the ACO patients. Conclusion In this group of COPD and ACO patients remotely diagnosed by pulmonologists, a substantial proportion would be considered to have asthma characteristics according to the guidelines. This may explain the high number of inhaled corticosteroid (ICS) prescriptions found in primary care COPD patients. Prospective studies are necessary to identify patients who may or may not benefit from ICS containing treatment. Hence, personalized care in primary care can be optimized.
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Affiliation(s)
- Anna Jetske Baron
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, Groningen, the Netherlands
| | - Bertine M J Flokstra-de Blok
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Department of Pediatric Pulmonology and Pediatric Allergology, University of Groningen, University Medical Center Groningen, Beatrix Children’s Hospital, Groningen, the Netherlands
| | - Ellen van Heijst
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Astma/COPD Dienst, CERTE Laboratories, Groningen, the Netherlands
| | - Roland A Riemersma
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Esther I Metting
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore
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20
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Chalmers JD, Laska IF, Franssen FME, Janssens W, Pavord I, Rigau D, McDonnell MJ, Roche N, Sin DD, Stolz D, Suissa S, Wedzicha J, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline. Eur Respir J 2020; 55:13993003.00351-2020. [PMID: 32366483 DOI: 10.1183/13993003.00351-2020] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 02/06/2023]
Abstract
Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question: should ICS be withdrawn in patients with COPD? The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendations formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, and feasibility and acceptability of interventions, the guideline panel made: 1) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations, 2) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ≥300 eosinophils·µL-1 and 3) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.A conditional recommendation indicates that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.
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Affiliation(s)
- James D Chalmers
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
| | - Irena F Laska
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,These three authors contributed equally to the development of this guideline
| | - Frits M E Franssen
- Dept of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Dept of Research and Education, CIRO, Horn, The Netherlands
| | - Wim Janssens
- Clinical Dept of Respiratory Diseases, UZ Leuven and Breathe, Dept CHROMETA, KU Leuven, Leuven, Belgium
| | - Ian Pavord
- Oxford NIHR Respiratory BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | | | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, AP-HP Centre University of Paris, Cochin Institute (UMR1016), Paris, France
| | - Don D Sin
- Centre for Heart Lung Innovation, St Paul's Hospital and Respiratory Division, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital and Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Jadwiga Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
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21
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Spece LJ, Donovan LM, Griffith MF, Keller T, Feemster LC, Smith NL, Au DH. Initiating Low-Value Inhaled Corticosteroids in an Inception Cohort with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2020; 17:589-595. [PMID: 31899652 PMCID: PMC7193812 DOI: 10.1513/annalsats.201911-854oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/03/2020] [Indexed: 01/08/2023] Open
Abstract
Rationale: Decreasing medication overuse represents an opportunity to avoid harm and costs in the era of value-based purchasing. Studies of inhaled corticosteroids (ICS) overuse in chronic obstructive pulmonary disease (COPD) have examined prevalent use. Understanding initiation of low-value ICS among complex patients with COPD may help shape deadoption efforts.Objectives: Examine ICS initiation among a cohort with low exacerbation risk COPD and test for associations with markers of patient and health system complexity.Methods: Between 2012 and 2016, we identified veterans with COPD from 21 centers. Our primary outcome was first prescription of ICS. We used the care assessment needs (CAN) score to assess patient-level complexity as the primary exposure. We used a time-to-event model with time-varying exposures over 1-year follow-up. We tested for effect modification using selected measures of health system complexity.Results: We identified 8,497 patients with COPD without an indication for ICS and did not have baseline use (inception cohort). Follow-up time was four quarters. Patient complexity by a continuous CAN score was associated with new dispensing of ICS (hazard ratio = 1.17 per 10-unit change; 95% confidence interval = 1.13-1.21). This association demonstrated a dose-response when examining quartiles of CAN score. Markers of health system complexity did not modify the association between patient complexity and first use of low-value ICS.Conclusions: Patient complexity may represent a symptom burden that clinicians are attempting to mitigate by initiating ICS. Lack of effect modification by health system complexity may reflect the paucity of structural support and low prioritization for COPD care.
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Affiliation(s)
- Laura J. Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Lucas M. Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Matthew F. Griffith
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Laura C. Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Nicholas L. Smith
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington
- Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington; and
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | - David H. Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
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Chang TY, Chien JY, Wu CH, Dong YH, Lin FJ. Comparative Safety and Effectiveness of Inhaled Corticosteroid and Long-Acting β2-Agonist Combinations in Patients With COPD. Chest 2020; 157:1117-1129. [DOI: 10.1016/j.chest.2019.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/03/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
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Keller T, Spece LJ, Donovan LM, Udris E, Coggeshall SS, Griffith M, Bryant AD, Casaburi R, Cooper JA, Criner GJ, Diaz PT, Fuhlbrigge AL, Gay SE, Kanner RE, Martinez FJ, Panos RJ, Shade D, Sternberg A, Stibolt T, Stoller JK, Tonascia J, Wise R, Yusen RD, Au DH, Feemster LC. Association of Guideline-Recommended COPD Inhaler Regimens With Mortality, Respiratory Exacerbations, and Quality of Life: A Secondary Analysis of the Long-Term Oxygen Treatment Trial. Chest 2020; 158:529-538. [PMID: 32278779 DOI: 10.1016/j.chest.2020.02.073] [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: 09/04/2019] [Revised: 02/04/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Although inhaled therapy reduces exacerbations among patients with COPD, the effectiveness of providing inhaled treatment per risk stratification models remains unclear. RESEARCH QUESTION Are inhaled regimens that align with the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy associated with clinically important outcomes? STUDY DESIGN AND METHODS We conducted secondary analyses of Long-term Oxygen Treatment Trial (LOTT) data. The trial enrolled patients with COPD with moderate resting or exertional hypoxemia between 2009 and 2015. Our exposure was the patient-reported inhaled regimen at enrollment, categorized as either aligning with, undertreating, or potentially overtreating per the 2017 GOLD strategy. Our primary composite outcome was time to death or first hospitalization for COPD. Additional outcomes included individual components of the composite outcome and time to first exacerbation. We generated multivariable Cox proportional hazard models across strata of GOLD-predicted exacerbation risk (high vs low) to estimate between-group hazard ratios for time to event outcomes. We adjusted models a priori for potential confounders, clustered by site. RESULTS The trial enrolled 738 patients (73.4% men; mean age, 68.8 years). Of the patients, 571 (77.4%) were low risk for future exacerbations. Of the patients, 233 (31.6%) reported regimens aligning with GOLD recommendations; most regimens (54.1%) potentially overtreated. During a 2.3-year median follow-up, 332 patients (44.9%) experienced the composite outcome. We found no difference in time to composite outcome or death among patients reporting regimens aligning with recommendations compared with undertreated patients. Among patients at low risk, potential overtreatment was associated with higher exacerbation risk (hazard ratio, 1.42; 95% CI, 1.09-1.87), whereas inhaled corticosteroid treatment was associated with 64% higher risk of pneumonia (incidence rate ratio, 1.64; 95% CI, 1.01-2.66). INTERPRETATION Among patients with COPD with moderate hypoxemia, we found no difference in clinical outcomes between inhaled regimens aligning with the 2017 GOLD strategy compared with those that were undertreated. These findings suggest the need to reevaluate the effectiveness of risk stratification model-based inhaled treatment strategies.
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Affiliation(s)
- Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Laura J Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Lucas M Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Edmunds Udris
- Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Scott S Coggeshall
- Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Matthew Griffith
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Alexander D Bryant
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Richard Casaburi
- Los Angeles Biomedical Research Institute at Harbor - UCLA Medical Center, Torrance, CA
| | - J Allen Cooper
- Birmingham VA Medical Center and the Lung Health Center, University of Alabama Birmingham, Birmingham, AL
| | | | - Philip T Diaz
- 201 Heart Lung Institute, Ohio State University School of Medicine, Columbus, OH
| | | | - Steven E Gay
- University of Michigan School of Medicine, Ann Arbor, MI
| | | | | | - Ralph J Panos
- Cincinnati VA Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Shade
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Alice Sternberg
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Thomas Stibolt
- Kaiser Permanente Center for Health Research, Portland, OR
| | | | - James Tonascia
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Robert Wise
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roger D Yusen
- Washington University School of Medicine, Saint Louis, MO
| | - David H Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
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Griffith MF, Feemster LC, Zeliadt SB, Donovan LM, Spece LJ, Udris EM, Au DH. Overuse and Misuse of Inhaled Corticosteroids Among Veterans with COPD: a Cross-sectional Study Evaluating Targets for De-implementation. J Gen Intern Med 2020; 35:679-686. [PMID: 31713043 PMCID: PMC7080925 DOI: 10.1007/s11606-019-05461-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/20/2019] [Accepted: 09/12/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Inhaled corticosteroid (ICS) use among patients with COPD increases the risk of pneumonia and other complications. Current recommendations limit ICS use to patients with frequent or severe COPD exacerbations. However, use of ICS among patients with COPD is common and may be occurring both among those with mild disease (overuse) and those misdiagnosed with COPD (misuse). OBJECTIVE To identify patients without identifiable indication for ICS and assess patient and provider characteristics associated with potentially inappropriate to targeted in de-implementation efforts DESIGN: We performed a cross-sectional study of patients with COPD in the Veterans Affairs (VA) system with recent spirometry. PARTICIPANTS After setting an index date, we identified individuals with a clinical diagnosis of COPD who had spirometry completed in the prior 5 years. We excluded individuals with an appropriate indication for ICS based on the 2017 GOLD statement, including asthma and a recent history of frequent or severe exacerbations. MAIN MEASURES ICS use without identifiable indication KEY RESULTS: We identified 26,536 patients with COPD without an identifiable indication for ICS. Nearly ¼ of patients (n = 6330) filled ≥2 prescriptions for ICS in the year prior to the index date. We found that older age (adjusted prevalence ratio [APR] 1.06 per decade, 95% confidence interval [CI] 1.04-1.08), white race (APR 1.11, 95% CI 1.05-1.19), and more primary care visits (APR 1.05 per visit, 95% CI 1.03-1.07) were associated with increased likelihood of potentially inappropriate use. Primary care clinic complexity and provider training were not associated with ICS use. Among patients misdiagnosed with COPD, we found that 14% used ICS. CONCLUSIONS Potentially inappropriate ICS use is common among patients with and without airflow obstruction who are diagnosed with COPD. We identified patient comorbidities and patterns of healthcare utilization that increase the likelihood of ICS use that could be targeted for system-level de-implementation interventions.
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Affiliation(s)
- Matthew F Griffith
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA.
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Laura C Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Steven B Zeliadt
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Lucas M Donovan
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Laura J Spece
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Edmunds M Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
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Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne ST, Wiener RS, Feemster L, Udris E, Au DH, Helfrich CD. De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives. J Gen Intern Med 2020; 35:51-56. [PMID: 31396814 PMCID: PMC6957635 DOI: 10.1007/s11606-019-05193-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/21/2018] [Accepted: 05/23/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. OBJECTIVE We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. DESIGN We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. PARTICIPANTS We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. MAIN MEASURES Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. KEY RESULTS Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. CONCLUSIONS Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.
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Affiliation(s)
- Krysttel Stryczek
- VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Colby Lea
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Chris Gillespie
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
| | - George Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | | | - Seppo T Rinne
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Laura Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Edmunds Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
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Tran D, Lim M, Vogrin S, Jayaram L. Point of Care Portable Spirometry in the Diagnosis and Treatment of Inpatients with Chronic Obstructive Pulmonary Disease. Lung 2020; 198:143-150. [PMID: 31894409 DOI: 10.1007/s00408-019-00314-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Spirometry is required to accurately diagnose chronic obstructive pulmonary disease (COPD). Following an acute exacerbation, it is recommended that spirometry be performed after a delay of 4-6 weeks to allow stability and a measure of 'baseline' lung function. However, poor attendance at these appointments can occur, leading to an inability to confirm the diagnosis of COPD or assess the severity of airflow obstruction. Portable spirometry (PS) is a proven surrogate device that may provide a convenient method to address these issues. The purpose of this study was to compare PS values, obtained prior to hospital discharge to laboratory-based spirometry (LS) results undertaken 4 weeks later. METHODS Thirty-three eligible inpatients with a clinically determined exacerbation of COPD were recruited. Patients underwent PS prior to discharge and LS 4 weeks later. RESULTS Reliability of PS values at discharge compared with outpatient LS 4 weeks later was excellent (intraclass correlation coefficient > 0.9). The PS confirmed a new diagnosis of COPD at the bedside in 29% of patients and excluded COPD in 6% at both time points. Patients were found to have a similar severity of airflow obstruction on both PS and LS, with clinical stability maintained between visits. The PS and LS may be used interchangeably for earlier diagnosis of COPD. PS at the point of discharge from hospital offers a unique opportunity to diagnose and facilitate COPD management from hospital to primary care.
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Affiliation(s)
- Donald Tran
- The University of Melbourne, Melbourne, Australia.,Department of Medicine, Respiratory & Sleep Disorders, Western Health, Melbourne, Australia
| | - Melvin Lim
- Department of Medicine, Respiratory & Sleep Disorders, Western Health, Melbourne, Australia
| | - Sara Vogrin
- The University of Melbourne, Melbourne, Australia
| | - Lata Jayaram
- The University of Melbourne, Melbourne, Australia. .,Department of Medicine, Respiratory & Sleep Disorders, Western Health, Melbourne, Australia.
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Suissa S, Dell'Aniello S, Ernst P. Comparative Effects of LAMA-LABA-ICS vs LAMA-LABA for COPD: Cohort Study in Real-World Clinical Practice. Chest 2019; 157:846-855. [PMID: 31759966 DOI: 10.1016/j.chest.2019.11.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/28/2019] [Accepted: 11/02/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Triple therapy combinations of a long-acting muscarinic antagonist (LAMA), a long-acting beta2-agonist (LABA), and an inhaled corticosteroid (ICS) for COPD were studied in randomized trials and observational studies, with variable results. We compared the effectiveness and safety of triple therapy with a LAMA-LABA combination in a real-world clinical practice setting. METHODS We identified a cohort of patients with COPD during 2002 through 2015, ≥ 55 years of age, from the UK's Clinical Practice Research Datalink. Patients initiating LAMA-LABA-ICS were matched 4:1 on time-conditional propensity scores with patients initiating LAMA-LABA, and followed for 1 year for the occurrence of a moderate or severe COPD exacerbation and severe pneumonia. RESULTS The cohort included 6,921 initiators of LAMA-LABA-ICS matched to 1,932 initiators of LAMA-LABA. The adjusted hazard ratio (HR) of a COPD exacerbation associated with LAMA-LABA-ICS initiation compared with LAMA-LABA initiation was 0.97 (95% CI, 0.87-1.08). For patients with blood eosinophil counts > 6%, the HR was 0.66 (95% CI, 0.46-0.94). For patients with two or more prior exacerbations, it was 0.83 (95% CI, 0.70-0.98). The incidence of severe pneumonia requiring hospitalization was increased with LAMA-LABA-ICS initiation (HR, 1.46; 95% CI, 1.03-2.06). CONCLUSIONS In a real-world setting of COPD treatment, the triple combination of LAMA, LABA, and ICS inhalers is generally as effective as combining LAMA and LABA inhalers in preventing COPD exacerbations. However, with the possible exception of patients with significant eosinophilia or frequent exacerbators, a LAMA-LABA combination without ICS may be preferable because it is associated with fewer severe cases of pneumonia.
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital; and the Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada.
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital; and the Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital; and the Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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Avdeev S, Aisanov Z, Arkhipov V, Belevskiy A, Leshchenko I, Ovcharenko S, Shmelev E, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD patients: rationale and algorithms. Int J Chron Obstruct Pulmon Dis 2019; 14:1267-1280. [PMID: 31354256 PMCID: PMC6572750 DOI: 10.2147/copd.s207775] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/17/2019] [Indexed: 12/17/2022] Open
Abstract
Observational studies indicate that overutilization of inhaled corticosteroids (ICS) is common in patients with chronic obstructive pulmonary disease (COPD). Overprescription and the high risk of serious ICS-related adverse events make withdrawal of this treatment necessary in patients for whom the treatment-related risks outweigh the expected benefits. Elaboration of an optimal, universal, user-friendly algorithm for withdrawal of ICS therapy has been identified as an important clinical need. This article reviews the available evidence on the efficacy, risks, and indications of ICS in COPD, as well as the benefits of ICS treatment withdrawal in patients for whom its use is not recommended by current guidelines. After discussing proposed approaches to ICS withdrawal published by professional associations and individual authors, we present a new algorithm developed by consensus of an international group of experts in the field of COPD. This relatively simple algorithm is based on consideration and integrated assessment of the most relevant factors (markers) influencing decision-making, such a history of exacerbations, peripheral blood eosinophil count, presence of infection, and risk of community-acquired pneumonia.
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Affiliation(s)
- Sergey Avdeev
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation.,Clinical Department, Federal Pulmonology Research Institute, Federal Medical and Biological Agency of Russia, Moscow, Russian Federation
| | - Zaurbek Aisanov
- Department of Pulmonology, N.I. Pirogov Russian State National Research Medical University, Moscow, Russian Federation
| | - Vladimir Arkhipov
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Andrey Belevskiy
- Department of Pulmonology, N.I. Pirogov Russian State National Research Medical University, Moscow, Russian Federation
| | - Igor Leshchenko
- Department of Phthisiology, Pulmonology and Thoracic Surgery, Ural State Medical University, Ekaterinburg, Russian Federation
| | - Svetlana Ovcharenko
- Department of Internal Diseases No.1, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Evgeny Shmelev
- Department of Differential Diagnostics, Federal Central Research Institute of Tuberculosis, Moscow, Russian Federation
| | - Marc Miravitlles
- Pneumology Department, University Hospital Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Dedman D, Coton SJ, Ghosh RE, Meeraus W, Crim C, Harvey C, Amelio J, Landis SH. Treatment Patterns of New Users of Fluticasone Furoate/Vilanterol in Asthma and COPD in UK Primary Care: Retrospective Cohort Study. Pulm Ther 2019; 5:81-95. [PMID: 32026429 PMCID: PMC6967316 DOI: 10.1007/s41030-019-0092-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction This retrospective database study explored treatment patterns and potential off-label prescribing among patients newly prescribed fluticasone furoate/vilanterol (FF/VI) in a UK primary care setting. Methods In Europe, FF/VI is approved in two strengths: 100/25 µg for adults with chronic obstructive pulmonary disease (COPD) and 100/25 µg or 200/25 µg for treatment of asthma in patients aged 12 or older. Using electronic health records from the Clinical Practice Research Datalink, new users of FF/VI or other inhaled corticosteroid/long-acting beta-agonist fixed-dose combination products were identified and classified into one of three groups: COPD diagnosis, asthma diagnosis, and other diagnosis (not COPD or asthma). Results During 2014–2015, 4373 patients initiated FF/VI: 3380 on FF/VI 100/25 (65% in the COPD diagnosis group) and 993 on FF/VI 200/25 (51% in the asthma diagnosis group). During up to 12 months of follow-up, the median number (interquartile range) of prescriptions of the index strength issued per patient was 7 (2–8) for FF/VI 100/25 and 5 (2–8) for FF/VI 200/25; most new users did not change from the index strength prescribed (93.0% COPD; 89.7% asthma, of all patients initiating treatment with FF/VI). Potential off-label FF/VI prescribing in children < 12 years old was rare (< 0.29% in the combined asthma and other diagnosis groups), and up to one in five new users of FF/VI with COPD were potentially prescribed FF/VI 200/25 off-label during the study period. Much of the potential off-label prescribing in COPD occurred in patients with a history of asthma, those presenting with greater disease severity, and/or prior treatment with high-dose steroids. Conclusions The prescription of FF/VI is rare in children under 12 years of age in the UK, according to our findings, but up to one in five COPD patients in the UK may have been prescribed FF/VI 200/25, some of which may have been off-label. Funding This study was funded by GlaxoSmithKline plc (study 205052). Study Registration GlaxoSmithKline plc Clinical Trial Registry study number 205052. Electronic supplementary material The online version of this article (10.1007/s41030-019-0092-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Dedman
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK.
| | - Sonia J Coton
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Rebecca E Ghosh
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Wilhelmine Meeraus
- GlaxoSmithKline plc, Epidemiology, Value Evidence and Outcomes, Stockley Park, Uxbridge, UK
| | - Courtney Crim
- GlaxoSmithKline plc, Research and Development, Research Triangle Park, NC, USA
| | - Catherine Harvey
- GlaxoSmithKline plc, Global Clinical Safety and Pharmacovigilance, Stockley Park, Uxbridge, UK
| | - Justyna Amelio
- GlaxoSmithKline plc, Epidemiology, Value Evidence and Outcomes, Stevenage, UK
| | - Sarah H Landis
- GlaxoSmithKline plc, Epidemiology, Value Evidence and Outcomes, Stockley Park, Uxbridge, UK
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Reilev M, Kristensen KB, Søndergaard J, Henriksen DP, Thompson W, Pottegård A. Discontinuation of therapy among COPD patients who experience an improvement in exacerbation status. Eur J Clin Pharmacol 2019; 75:1025-1032. [PMID: 30903196 DOI: 10.1007/s00228-019-02667-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/12/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE A subset of patients with chronic obstructive pulmonary disease (COPD) experience a decrease in exacerbation frequency, leading to a diminished need for treatment with inhaled corticosteroids (ICS). We investigated prescribing and discontinuation patterns of long-acting bronchodilators and ICS in COPD patients according to exacerbation frequency. METHODS Using the nationwide Danish health registries, we conducted a drug utilization study among patients who had at least two exacerbations or one hospitalization due to an exacerbation during 2011-2012. This study population was stratified according to consistency of exacerbation occurrence after 12, 24, 36, and 48 months of follow-up and the groups were described according to use of ICS, long-acting β2-agonists (LABA), and long-acting anticholinergics (LAMA), and combinations thereof. RESULTS We identified 29,010 COPD exacerbators during 2011-2012. Upon inclusion, 70% received ICS-containing regimens, in combination with LABA (23%) or both LABA and LAMA (41%). The proportion of prevalent users of ICS-containing regimens decreased to 56% during follow-up among exacerbation-free individuals, while it increased to 86% in individuals who experienced at least one exacerbation annually. Persistence to ICS-containing regimens was 58% after 4 years in individuals without exacerbations compared to 74% among those with annual exacerbations. Similar patterns were observed for triple therapy which was the most extensively used drug combination regardless of consistency of exacerbation occurrence. CONCLUSIONS The extensive use of ICS and the relatively high persistence to ICS-containing regimens in individuals who had a decrease in exacerbation occurrence highlight a need for the development and implementation of de-escalation strategies in clinical practice.
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Affiliation(s)
- Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark.
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark.
| | - Kasper Bruun Kristensen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
| | | | - Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
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Provost KA, Smith M, Miller-Larsson A, Gudleski GD, Sethi S. Bacterial regulation of macrophage bacterial recognition receptors in COPD are differentially modified by budesonide and fluticasone propionate. PLoS One 2019; 14:e0207675. [PMID: 30677037 PMCID: PMC6345465 DOI: 10.1371/journal.pone.0207675] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 11/05/2018] [Indexed: 11/18/2022] Open
Abstract
Rationale Patients with COPD have an increased risk for community-acquired pneumonia, which is further increased by inhaled corticosteroids. Objective To assess effects of the corticosteroids, budesonide and fluticasone propionate, on macrophage bacterial responses in COPD. Methods Monocyte-derived macrophages (MDMs) generated from blood monocytes from 10 non-smoker controls (NoS), 20 smokers without COPD (Sm), and 40 subjects with moderate to severe COPD (21 ex-smokers (COPD-ES) and 19 current smokers (COPD-S)) were pre-treated with budesonide or fluticasone (10 nM—1 μM) and challenged with live non-typeable Haemophilus influenzae (NTHI) or Streptococcus pneumoniae (SP). Cell surface bacterial recognition receptor expression (flow cytometry) and cytokine release (bead array) were analyzed. Results NTHI and SP reduced bacterial recognition receptor expression on MDMs from COPD and Sm, but not NoS (except TLR4). SR-AI and MARCO were reduced by both NTHI and SP, whereas other receptors by either NTHI or SP. Among COPD subjects, COPD-ES demonstrated a greater number of reductions as compared to COPD-S. NTHI reduced SR-AI, MARCO, CD11b, CD35 and CD206 in COPD-ES while only SR-AI and CD11b in COPD-S. SP reduced SRA-1, CD1d, TLR2 and TLR4 in both COPD-ES and COPD-S, and reduced MARCO and CD93 only in COPD-ES. All receptors reduced in COPD by NTHI and most by SP, were also reduced in Sm. Budesonide counteracted the receptor reductions induced by both NTHI (CD206 p = 0.03, MARCO p = 0.08) and SP (SR-AI p = 0.02) in COPD-ES. Fluticasone counteracted only SP-induced reductions in TLR2 (p = 0.008 COPD-ES and p = 0.04 COPD-S) and TLR4 (p = 0.02 COPD-ES). Cytokine release was equivalently reduced by both corticosteroids. Conclusions Reduction in macrophage bacterial recognition receptors during bacterial exposure could provide a mechanism for the increased pneumonia risk in COPD. Differential effects of budesonide and fluticasone propionate on macrophage bacterial recognition receptor expression may contribute to the higher pneumonia incidence reported with fluticasone propionate.
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Affiliation(s)
- Karin A. Provost
- Veterans Health Administration, Veterans Affairs Western New York Healthcare System at Buffalo, Division of Pulmonary, Critical Care and Sleep Medicine, Buffalo, New York, United States of America
- University at Buffalo, State University of New York, Jacobs School of Medicine and Biomedical Sciences, Division of Pulmonary, Critical Care and Sleep Medicine, Buffalo, New York, United States of America
- * E-mail:
| | - Miyuki Smith
- Veterans Health Administration, Veterans Affairs Western New York Healthcare System at Buffalo, Division of Pulmonary, Critical Care and Sleep Medicine, Buffalo, New York, United States of America
| | | | - Gregory D. Gudleski
- University at Buffalo, State University of New York, Jacobs School of Medicine and Biomedical Sciences, Department of Medicine, Buffalo, New York, United States of America
| | - Sanjay Sethi
- Veterans Health Administration, Veterans Affairs Western New York Healthcare System at Buffalo, Division of Pulmonary, Critical Care and Sleep Medicine, Buffalo, New York, United States of America
- University at Buffalo, State University of New York, Jacobs School of Medicine and Biomedical Sciences, Division of Pulmonary, Critical Care and Sleep Medicine, Buffalo, New York, United States of America
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Shin SH, Park HY, Kang D, Cho J, Kwon SO, Park JH, Lee JS, Oh YM, Sin DD, Kim WJ, Lee SD. Serial blood eosinophils and clinical outcome in patients with chronic obstructive pulmonary disease. Respir Res 2018; 19:134. [PMID: 30001715 PMCID: PMC6044087 DOI: 10.1186/s12931-018-0840-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/05/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Blood eosinophils have been suggested as a potential biomarker in chronic obstructive pulmonary disease (COPD), and their stability over time has been investigated in a few studies. However, the association between the stability of blood eosinophils and long-term clinical outcomes in COPD patients has yet to be fully elucidated. This study aimed to evaluate the stability of blood eosinophils and its association with clinical outcomes in COPD patients. METHODS In total, 299 COPD patients from the Korean Obstructive Lung Disease cohort with at least two blood eosinophil measurements were included. Patients were stratified according to a cut-off of 300 cells/μL, and the association between eosinophil changes and all-cause mortality was analysed. The annual decline in forced expiratory volume in 1 s (FEV1), serial changes in St George's Respiratory Questionnaire score (SGRQ), and exacerbations during follow-up were compared among eosinophil groups. RESULTS Patients were stratified into three groups according to the blood eosinophil cut-off: persistently < 300 cells/μL (PL; n = 175), variable (V; n = 68), and persistently ≥300 cells/μL (PH; n = 56). There were no significant differences in baseline characteristics (age, sex, smoking, body mass index, use of inhaled corticosteroids, exacerbations in the previous year, FEV1 (L or % predicted), or emphysema score) among the groups. During a median follow-up of 6.0 years, the PH group had a better survival rate than the PL group (adjusted mortality rate ratio, 0.29; 95% confidence interval, 0.09-0.97; P = 0.045). The PH group also showed improved symptoms and impact domains of SGRQ score compared to the PL group. No difference was found in annual FEV1 decline or exacerbations during follow-up among the groups. CONCLUSIONS Patients with persistently high blood eosinophils had a better survival rate than those with persistently low blood eosinophils. Serial follow-up of blood eosinophils could help to predict outcomes in COPD patients.
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Affiliation(s)
- Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Danbee Kang
- Departments of Health Sciences and Technology and Clinical Research Design and Evaluation, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Juhee Cho
- Departments of Health Sciences and Technology and Clinical Research Design and Evaluation, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Cancer Education Center, Samsung Comprehensive Cancer Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Departments of Health, Behavior, and Society and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sung Ok Kwon
- Biomedical Research Institute, Kangwon National University Hospital, Chuncheon, South Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, South Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Don D Sin
- Respiratory Division, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Woo Jin Kim
- Department of Internal Medicine and Environmental Health Center, Kangwon National University Hospital, School of Medicine, Kangwon National University, 156 Baengyeong-ro, Chuncheon-si, Gangwon-do, 200-722, South Korea.
| | - Sang-Do Lee
- Department of Pulmonary and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Cataldo D, Derom E, Liistro G, Marchand E, Ninane V, Peché R, Slabbynck H, Vincken W, Janssens W. Overuse of inhaled corticosteroids in COPD: five questions for withdrawal in daily practice. Int J Chron Obstruct Pulmon Dis 2018; 13:2089-2099. [PMID: 30013336 PMCID: PMC6039066 DOI: 10.2147/copd.s164259] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Evidence and guidelines are becoming increasingly clear about imbalance between the risks and benefits of inhaled corticosteroids (ICSs) in patients with COPD. While selected patients may benefit from ICS-containing regimens, ICSs are often inappropriately prescribed with - according to Belgian market research data - up to 70% of patients in current practice receiving ICSs, usually as a fixed combination with a long-acting β2-adrenoreceptor agonist. Studies and recommendations support withdrawal of ICSs in a large group of patients with COPD. However, historical habits appear difficult to change even in the light of recent scientific evidence. We have built a collaborative educational platform with chest physicians and primary care physicians to increase awareness and provide guidance and support in this matter.
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Affiliation(s)
- Didier Cataldo
- Department of Respiratory Medicine, Centre Hospitalier Universitaire de Liège (CHU) and University of Liège, Liège, Belgium,
| | - Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Gent, Belgium
| | - Giuseppe Liistro
- Department of Respiratory Medicine, University Hospitals Saint-Luc, Brussels, Belgium
| | - Eric Marchand
- Department of Respiratory Medicine, University Hospital UCL Namur, Yvoir, Belgium
- URPhyM, University of Namur, Namur, Belgium
| | - Vincent Ninane
- Department of Respiratory Medicine, University Hospital Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Rudi Peché
- Department of Respiratory Medicine, University Hospital Vésale, Montigny-le-Tilleul, Belgium
| | - Hans Slabbynck
- Department of Respiratory Medicine, ZNA Middelheim, Antwerpen, Belgium
| | - Walter Vincken
- Respiratory Division, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | - Wim Janssens
- Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
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Miravitlles M, Baek S, Vithlani V, Lad R. Optimal Bronchodilation for COPD Patients: Are All Long-Acting β₂-Agonist/Long-Acting Muscarinic Antagonists the Same? Tuberc Respir Dis (Seoul) 2018; 81:198-215. [PMID: 29926556 PMCID: PMC6030660 DOI: 10.4046/trd.2018.0040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 04/26/2018] [Accepted: 04/29/2018] [Indexed: 12/21/2022] Open
Abstract
Bronchodilators provide improvements in lung function and reductions in symptoms and exacerbations, and are the mainstay of pharmacological management of chronic obstructive pulmonary disease (COPD). The Global Initiative for Chronic Obstructive Lung Disease strategy recommends the use of a combination of long-acting β₂-agonist/long-acting muscarinic antagonists (LABA/LAMA) as the first-line treatment option in the majority of symptomatic patients with COPD. This review provides an indirect comparison of available LABA/LAMA fixed-dose combinations (FDCs) through discussion of important efficacy and safety data from the key literature, with the objective of providing physicians with a framework for informed decision-making. LABA/LAMA FDCs provided greater benefits compared with placebo and similar or greater benefits compared with tiotropium and salmeterol/fluticasone in improving lung function, dyspnea, health-related quality of life, reducing rescue medication use and preventing exacerbations, although with some variability in efficacy between individual FDCs; further, tolerability profiles were comparable among LABA/LAMA FDCs. However, there is a disparity in the amount of evidence generated for different LABA/LAMA FDCs. Thus, this review shows that all LABA/LAMA FDCs may not be the same and that care should be taken when extrapolating individual treatment outcomes to the entire drug class. It is important that physicians consider the efficacy gradient that exists among LABA/LAMA FDCs, and factors such as inhaler devices and potential biomarkers, when choosing the optimal bronchodilator treatment for long-term management of patients with COPD.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
| | | | | | - Rahul Lad
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
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Chronic obstructive pulmonary disease in the long-term care setting: current practices, challenges, and unmet needs. Curr Opin Pulm Med 2018; 23 Suppl 1:S1-S28. [PMID: 28990958 DOI: 10.1097/mcp.0000000000000416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
: Chronic obstructive pulmonary disease (COPD) is a prevalent and disabling disorder in the United States, especially affecting older individuals, women, and those with a history of smoking. Studies show that COPD may be underrepresented, underdiagnosed, and undertreated in elderly patients residing in long-term care (LTC) facilities. The quality of care for LTC residents with COPD is heterogeneous in regard to both the facility and the patient. For LTC facilities, care should be driven by staff education, interstaff communication, and interfacility communication. From the perspective of the LTC patient, choice of medication and device should be based on appropriate diagnosis, comorbidities, ability to perform treatment, and patient preferences. Nebulization is currently underutilized in LTC settings, although it would benefit older patients with low peak inspiratory flow, cognitive impairment, and/or physical impairment, which may preclude them from using other inhalation devices. Authors developed a COPD treatment algorithm that focuses on three primary patient aspects to consider when deciding on respiratory device in patients in LTC facilities: inspiratory flow, hand dexterity and coordination, and cognitive capacity.
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van den Berge M, Jonker MR, Miller-Larsson A, Postma DS, Heijink IH. Effects of fluticasone propionate and budesonide on the expression of immune defense genes in bronchial epithelial cells. Pulm Pharmacol Ther 2018; 50:47-56. [PMID: 29627483 DOI: 10.1016/j.pupt.2018.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/07/2018] [Accepted: 04/04/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND COPD patients have increased risk of pneumonia when treated with fluticasone propionate (FP), whereas this is generally not the case with budesonide (BUD) treatment. We hypothesized that BUD and FP differentially affect the expression of immune defense genes. METHODS Human bronchial epithelial 16HBE cells and air-liquid interface (ALI)-cultured primary bronchial epithelial cells (PBECs) were pre-treated with clinically equipotent concentrations of BUD or FP (0.16-16 nM BUD and 0.1-10 nM FP), and the expression of immune defense genes was studied at baseline and after exposure to rhinovirus (RV16). RESULTS Using microfluidic cards, we observed that both BUD and FP significantly suppressed CXCL8, IFNB1 and S100A8 mRNA expression in unstimulated 16HBE cells. Interestingly, BUD, but not FP, significantly increased lactotransferrin (LTF) expression. The difference between the effect of BUD and FP on LTF expression was statistically significant and confirmed by qPCR and at the protein level by western blotting. RV16 infection of ALI-cultured PBECs significantly increased the expression of CCL20, IFNB1 and S100A8, but not of LTF or CAMP/LL-37. In these RV16-exposed cells, LTF expression was again significantly higher upon pre-treatment with BUD than with FP. The same was observed for S100A8, but not for CCL20, IFNB1 or CAMP/LL-37 expression. CONCLUSIONS Treatment of human bronchial epithelial cells with BUD results in significantly higher expression of specific immune defense genes than treatment with FP. The differential regulation of these immune defense genes may help to explain the clinical observation that BUD and FP treatment differ with respect to the risk of developing pneumonia in COPD.
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Affiliation(s)
- M van den Berge
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases, GRIAC Research Institute, Groningen, The Netherlands; University of Groningen, University Medical Centre Groningen, GRIAC Research Institute, Groningen, The Netherlands
| | - M R Jonker
- University of Groningen, University Medical Centre Groningen, Department of Pathology & Medical Biology, Experimental Pulmonology and Inflammation Research, Mölndal, Sweden
| | - A Miller-Larsson
- AstraZeneca Gothenburg, Department of Respiratory GMed, Mölndal, Sweden
| | - D S Postma
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases, GRIAC Research Institute, Groningen, The Netherlands; University of Groningen, University Medical Centre Groningen, GRIAC Research Institute, Groningen, The Netherlands
| | - I H Heijink
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases, GRIAC Research Institute, Groningen, The Netherlands; University of Groningen, University Medical Centre Groningen, GRIAC Research Institute, Groningen, The Netherlands; University of Groningen, University Medical Centre Groningen, Department of Pathology & Medical Biology, Experimental Pulmonology and Inflammation Research, Mölndal, Sweden.
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Matera MG, Calzetta L, Puxeddu E, Rogliani P, Cazzola M. A safety comparison of LABA+LAMA vs LABA+ICS combination therapy for COPD. Expert Opin Drug Saf 2018; 17:509-517. [DOI: 10.1080/14740338.2018.1448786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Maria Gabriella Matera
- Department of Experimental Medicine, Unit of Pharmacology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luigino Calzetta
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ermanno Puxeddu
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine and Surgery, Unit of Respiratory Medicine, University of Rome Tor Vergata, Rome, Italy
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Balkissoon R. New Treatment Options for COPD: How Do We Decide Phenotypes, Endotypes or Treatable Traits? CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:72-80. [PMID: 29629407 DOI: 10.15326/jcopdf.5.1.2018.0128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Ariel A, Altraja A, Belevskiy A, Boros PW, Danila E, Fležar M, Koblizek V, Fridlender ZG, Kostov K, Krams A, Milenkovic B, Somfay A, Tkacova R, Tudoric N, Ulmeanu R, Valipour A. Inhaled therapies in patients with moderate COPD in clinical practice: current thinking. Int J Chron Obstruct Pulmon Dis 2017; 13:45-56. [PMID: 29317810 PMCID: PMC5743110 DOI: 10.2147/copd.s145573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COPD is a complex, heterogeneous condition. Even in the early clinical stages, COPD carries a significant burden, with breathlessness frequently leading to a reduction in exercise capacity and changes that correlate with long-term patient outcomes and mortality. Implementation of an effective management strategy is required to reduce symptoms, preserve lung function, quality of life, and exercise capacity, and prevent exacerbations. However, current clinical practice frequently differs from published guidelines on the management of COPD. This review focuses on the current scientific evidence and expert opinion on the management of moderate COPD: the symptoms arising from moderate airflow obstruction and the burden these symptoms impose, how physical activity can improve disease outcomes, the benefits of dual bronchodilation in COPD, and the limited evidence for the benefits of inhaled corticosteroids in this disease. We emphasize the importance of maximizing bronchodilation in COPD with inhaled dual-bronchodilator treatment, enhancing patient-related outcomes, and enabling the withdrawal of inhaled corticosteroids in COPD in well-defined patient groups.
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Affiliation(s)
- Amnon Ariel
- Emek Medical Center, Clalit Healthcare Services, Afula, Israel
| | - Alan Altraja
- Department of Pulmonary Medicine, University of Tartu
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Andrey Belevskiy
- Department of Pulmonology, Russian National Research Medical University, Moscow, Russia
| | - Piotr W Boros
- Lung Pathophysiology Department, National TB and Lung Diseases Research Institute, Warsaw, Poland
| | - Edvardas Danila
- Clinic of Infectious Chest Diseases, Dermatovenereology, and Allergology, Vilnius University, Centre of Pulmonology and Allergology, Vilnius University Hospital, Vilnius, Lithuania
| | - Matjaz Fležar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Vladimir Koblizek
- Department of Pneumology, University Hospital, Hradec Králové, Czech Republic
| | - Zvi G Fridlender
- Institute of Pulmonary Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Kosta Kostov
- Clinic of Pulmonary Diseases, Military Medical Academy, Sofia, Bulgaria
| | - Alvils Krams
- Medical Faculty of Latvian University, Riga East University Hospital, Riga, Latvia
| | - Branislava Milenkovic
- Clinic for Pulmonary Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Attila Somfay
- Department of Pulmonology, University of Szeged, Deszk, Hungary
| | - Ruzena Tkacova
- Department of Respiratory Medicine and Tuberculosis, Faculty of Medicine, PJ Safarik University, Košice, Slovakia
| | - Neven Tudoric
- School of Medicine, Dubrava University Hospital, Zagreb, Croatia
| | | | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
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Miravitlles M, Cosío BG, Arnedillo A, Calle M, Alcázar-Navarrete B, González C, Esteban C, Trigueros JA, Rodríguez González-Moro JM, Quintano Jiménez JA, Baloira A. A proposal for the withdrawal of inhaled corticosteroids in the clinical practice of chronic obstructive pulmonary disease. Respir Res 2017; 18:198. [PMID: 29183382 PMCID: PMC5706374 DOI: 10.1186/s12931-017-0682-y] [Citation(s) in RCA: 33] [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: 10/23/2017] [Accepted: 11/15/2017] [Indexed: 01/24/2023] Open
Abstract
According to the current clinical practice guidelines for chronic obstructive pulmonary disease (COPD), the addition of inhaled corticosteroids (ICS) to long-acting β2 agonist therapy is recommended in patients with moderate-to-severe disease and an increased risk of exacerbations. However, ICS are largely overprescribed in clinical practice, and most patients are unlikely to benefit from long-term ICS therapy.Evidence from recent randomized-controlled trials supports the hypothesis that ICS can be safely and effectively discontinued in patients with stable COPD and in whom ICS therapy may not be indicated, without detrimental effects on lung function, health status, or risk of exacerbations. This article summarizes the evidence supporting the discontinuation of ICS therapy, and proposes an algorithm for the implementation of ICS withdrawal in patients with COPD in clinical practice.Given the increased risk of potentially serious adverse effects and complications with ICS therapy (including pneumonia), the use of ICS should be limited to the minority of patients in whom the treatment effects outweigh the risks.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Borja G Cosío
- CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Department of Respiratory Medicine, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Spain
| | - Aurelio Arnedillo
- Pneumology, Allergy and Thoracic Surgery Department, Hospital Universitario Puerta del Mar, Cádiz, Spain
- Medicine Department, University of Cádiz, Cádiz, Spain
| | - Myriam Calle
- Pulmonary Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Bernardino Alcázar-Navarrete
- Respiratory Department, AIG de Medicina, Hospital de Alta Resolución de Loja, Agencia Sanitaria Hospital de Poniente, Loja, Granada, Spain
| | - Cruz González
- Department of Respiratory Medicine, Hospital Clínico Universitario and Instituto de Investigación Sanitaria (INCLIVA) Valencia, Valencia, Spain
| | - Cristóbal Esteban
- Pneumology Department of Hospital Galdakao-Usansolo, Biscay, Spain
- Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Bilbao, Spain
| | | | | | | | - Adolfo Baloira
- Servicio de Neumología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
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Self TH, Ellingson S. New Treatment Option for Chronic Obstructive Pulmonary Disease: Two Long-Acting Bronchodilators in a Single Metered-Dose Inhaler. Am J Med 2017; 130:1251-1254. [PMID: 28757318 DOI: 10.1016/j.amjmed.2017.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 11/15/2022]
Abstract
Combination long-acting inhaled bronchodilators are central to the management of patients with moderate to very severe chronic obstructive pulmonary disease. Glycopyrrolate is a long-acting muscarinic antagonist (LAMA), and formoterol fumarate is a long-acting beta2 agonist (LABA). In randomized controlled trials, this LAMA/LABA combination in a metered-dose inhaler was shown to be effective in improving pulmonary function and quality of life. Clinicians now have the availability of 3 delivery systems for LAMA/LABA therapy, including metered-dose inhaler, dry-powder inhaler, and Soft Mist inhaler. On the basis of numerous patient factors, such as cognitive ability, manual strength/dexterity, and peak inspiratory flow, clinicians may select the most appropriate inhalation device. For each inhalation device, persistent patient education is absolutely essential, including observation of patient use. International evidence-based guidelines stress the critical importance of ensuring correct use of inhalation devices.
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Affiliation(s)
- Timothy H Self
- University of Tennessee Health Science Center, Methodist University Hospital, Memphis.
| | - Samantha Ellingson
- University of Tennessee Health Science Center, PGY2 Internal Medicine Pharmacy Residency, Methodist University Hospital, Memphis
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The Reemergence of the Asthma-COPD Overlap Syndrome: Characterizing a Syndrome in the Precision Medicine Era. Curr Allergy Asthma Rep 2017; 16:81. [PMID: 27796796 DOI: 10.1007/s11882-016-0660-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The asthma-COPD overlap syndrome (ACOS) has reemerged in the medical literature. This review addresses our current understanding of ACOS as a clinical and biological entity and how new and existing therapies may be targeted to this group. RECENT FINDINGS Many studies suggest that ACOS is common and associated with more morbidity than asthma and COPD in general. However, there is no consensus on an ACOS definition, likely due to the heterogeneity of the disease. Variable definitions have led to variable results in ACOS studies. Given this clinical variability, biomarkers (e.g., eosinophils and type 2 inflammatory markers) are increasingly being used to identify an ACOS molecular phenotype which appears to be more responsive to inhaled corticosteroids. Although ACOS has become a popular diagnosis, it is unclear whether identifying ACOS as a separate disease entity is clinically useful. Future studies should focus on identifying key clinical features and biomarkers that characterize vulnerable and treatment-responsive patients.
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Roche N, Chapman KR, Vogelmeier CF, Herth FJF, Thach C, Fogel R, Olsson P, Patalano F, Banerji D, Wedzicha JA. Blood Eosinophils and Response to Maintenance Chronic Obstructive Pulmonary Disease Treatment. Data from the FLAME Trial. Am J Respir Crit Care Med 2017; 195:1189-1197. [PMID: 28278391 DOI: 10.1164/rccm.201701-0193oc] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Post hoc analyses suggest that blood eosinophils have potential as a predictive biomarker of inhaled corticosteroid efficacy in the management of chronic obstructive pulmonary disease (COPD). OBJECTIVES We prospectively investigated the value of blood eosinophils as a predictor of responsiveness to an inhaled corticosteroid/long-acting β2-agonist combination versus a long-acting β2-agonist/long-acting muscarinic antagonist combination for exacerbation prevention. METHODS We conducted prespecified analyses of data from the FLAME (Effect of Indacaterol Glycopyronium vs Fluticasone Salmeterol on COPD Exacerbations) study, which compared once-daily long-acting β2-agonist/long-acting muscarinic antagonist indacaterol/glycopyrronium 110/50 μg with twice-daily long-acting β2-agonist/inhaled corticosteroid salmeterol/fluticasone combination 50/500 μg in patients with one or more exacerbations in the preceding year. Subsequent post hoc analyses were conducted to address further cutoffs and endpoints. MEASUREMENTS AND MAIN RESULTS We compared treatment efficacy according to blood eosinophil percentage (<2% and ≥2%, <3% and ≥3%, and <5% and ≥5%) and absolute blood eosinophil count (<150 cells/μl, 150 to <300 cells/μl, and ≥300 cells/μl). Indacaterol/glycopyrronium was significantly superior to salmeterol/fluticasone for the prevention of exacerbations (all severities, or moderate or severe) in the <2%, ≥2%, <3%, <5%, and <150 cells/μl subgroups, and at no cutoff was salmeterol/fluticasone superior to indacaterol/glycopyrronium. Furthermore, the rate of moderate or severe exacerbations did not increase with increasing blood eosinophils. The incidence of pneumonia was higher in patients receiving salmeterol/fluticasone than indacaterol/glycopyrronium in both the <2% and ≥2% subgroups. CONCLUSIONS Our prospective analyses indicate that indacaterol/glycopyrronium provides superior or similar benefits over salmeterol/fluticasone regardless of blood eosinophil levels in patients with COPD. Clinical trial registered with www.clinicaltrials.gov (NCT01782326).
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Affiliation(s)
- Nicolas Roche
- 1 Service de Pneumologie AP-HP, University Paris Descartes (EA2511), Paris, France
| | - Kenneth R Chapman
- 2 Asthma and Airway Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Claus F Vogelmeier
- 3 Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Felix J F Herth
- 4 Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
| | - Chau Thach
- 5 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Robert Fogel
- 5 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | - Donald Banerji
- 5 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Jadwiga A Wedzicha
- 8 National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Chalmers JD, Tebboth A, Gayle A, Ternouth A, Ramscar N. Determinants of initial inhaled corticosteroid use in patients with GOLD A/B COPD: a retrospective study of UK general practice. NPJ Prim Care Respir Med 2017; 27:43. [PMID: 28663549 PMCID: PMC5491501 DOI: 10.1038/s41533-017-0040-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 05/22/2017] [Accepted: 05/25/2017] [Indexed: 01/09/2023] Open
Abstract
Initial use of inhaled corticosteroid therapy is common in patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) A or B chronic obstructive pulmonary disease, contrary to GOLD guidelines. We investigated UK prescribing of inhaled corticosteroid therapy in these patients, to identify predictors of inhaled corticosteroid use in newly diagnosed chronic obstructive pulmonary disease patients. A cohort of newly diagnosed GOLD A/B chronic obstructive pulmonary disease patients was identified from the UK Clinical Practice Research Datalink (June 2005-June 2015). Patients were classified by prescribed treatment, with those receiving inhaled corticosteroid-containing therapy compared with those receiving long-acting bronchodilators without inhaled corticosteroid. In all, 29,815 patients with spirometry-confirmed chronic obstructive pulmonary disease were identified. Of those prescribed maintenance therapy within 3 months of diagnosis, 63% were prescribed inhaled corticosteroid-containing therapy vs. 37% prescribed non-inhaled corticosteroid therapy. FEV1% predicted, concurrent asthma diagnosis, region, and moderate exacerbation were the strongest predictors of inhaled corticosteroid use in the overall cohort. When concurrent asthma patients were excluded, all other co-variates remained significant predictors. Other significant predictors included general practitioner practice, younger age, and co-prescription with short-acting bronchodilators. Trends over time showed that initial inhaled corticosteroid prescriptions reduced throughout the study, but still accounted for 47% of initial prescriptions in 2015. These results suggest that inhaled corticosteroid prescribing in GOLD A/B patients is common, with significant regional variation that is independent of FEV1% predicted. EARLY-STAGE CHRONIC LUNG DISEASE OVERUSE OF INHALED STEROIDS IN THE UK: Inhaled steroids are often prescribed to early-stage chronic lung disease patients in the UK despite guidelines to the contrary. Patients newly diagnosed with early-stage chronic obstructive pulmonary disease (COPD) should not be prescribed inhaled corticosteroids (ICS), because they carry an increased risk of side effects such as pneumonia and osteoporosis. ICS should be reserved for patients with severe COPD and frequent exacerbations. James Chalmers at the Scottish Centre for Respiratory Research, Dundee, and co-workers examined prescribed medication data from the UK spanning 10 years, to determine key predictors of ICS prescription during early-stage COPD. Of 29,815 patients identified, an average of 63% were prescribed ICS upon diagnosis, regardless of disease severity. Younger patients were more likely to receive ICS, possibly due to co-morbidity with chronic asthma, and particular UK regions and medical practices prescribed ICS more readily than others.
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Affiliation(s)
- James D Chalmers
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland
| | | | - Alicia Gayle
- Boehringer Ingelheim Ltd., Bracknell, Berkshire, UK
| | | | - Nick Ramscar
- Boehringer Ingelheim Ltd., Bracknell, Berkshire, UK
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Differences in the coronal proteome acquired by particles depositing in the lungs of asthmatic versus healthy humans. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2017. [PMID: 28647590 DOI: 10.1016/j.nano.2017.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Most inhaled nanomedicines in development are for the treatment of lung disease, yet little is known about their interaction with the respiratory tract lining fluids (RTLFs). Here we combined the use of nano-silica, as a protein concentrator, with label-free snapshot proteomics (LC-MS/MS; key findings confirmed by ELISA) to generate a quantitative profile of the RTLF proteome and provided insight into the evolved corona; information that may be used in future to improve drug targeting to the lungs by inhaled medicines. The asthmatic coronal proteome displayed a reduced contribution of surfactant proteins (SP-A and B) and a higher contribution of α1-antitrypsin. Pathway analysis suggested that asthmatic RTLFs may also be deficient in proteins related to metal handling (e.g. lactoferrin). This study demonstrates how the composition of the corona acquired by inhaled nanoparticles is modified in asthma and suggests depressed mucosal immunity even in mild airway disease.
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Hollis S, Jorup C, Lythgoe D, Martensson G, Regnell P, Eckerwall G. Risk of pneumonia with budesonide-containing treatments in COPD: an individual patient-level pooled analysis of interventional studies. Int J Chron Obstruct Pulmon Dis 2017; 12:1071-1084. [PMID: 28435240 PMCID: PMC5389656 DOI: 10.2147/copd.s128358] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Concerns have been raised that treatment of COPD with inhaled corticosteroids may increase pneumonia risk. Responding to a request from the European Medicines Agency Pharmacovigilance Risk Assessment Committee, a pooled analysis of interventional studies compared pneumonia risk with inhaled budesonide-containing versus non-budesonide-containing treatments and the impact of other clinically relevant factors. Methods AstraZeneca-sponsored, parallel-group, double-blind, randomized controlled trials meeting the following criteria were included: >8 weeks’ duration; ≥60 patients with COPD; inhaled budesonide treatment arm (budesonide/formoterol or budesonide); and non-budesonide-containing comparator arm (formoterol or placebo). Primary and secondary outcomes were time to first pneumonia treatment-emergent serious adverse event (TESAE) and treatment-emergent adverse event (TEAEs), respectively, analyzed using Cox regression models stratified by study. Results Eleven studies were identified; 10,570 out of 10,574 randomized patients receiving ≥1 dose of study treatment were included for safety analysis (budesonide-containing, n=5,750; non-budesonide-containing, n=4,820). Maximum exposure to treatment was 48 months. The overall pooled hazard ratio (HR), comparing budesonide versus non-budesonide-containing treatments, was 1.15 for pneumonia TESAEs (95% confidence interval [CI]: 0.83, 1.57) and 1.13 for pneumonia TEAEs (95% CI: 0.94, 1.36). The annual incidence of pneumonia TESAEs was 1.9% and 1.5% for budesonide-containing and non-budesonide-containing treatments, respectively. Comparing budesonide/formoterol with non-budesonide-containing treatment, the HRs for pneumonia TESAEs and TEAEs were 1.00 (95% CI: 0.69, 1.44) and 1.21 (95% CI: 0.93, 1.57), respectively. For budesonide versus placebo, HRs were 1.57 for pneumonia TESAEs (95% CI: 0.90, 2.74) and 1.07 for pneumonia TEAEs (95% CI: 0.83, 1.38). Conclusion This pooled analysis found no statistically significant increase in overall risk for pneumonia TESAEs or TEAEs with budesonide-containing versus non-budesonide-containing treatments. However, a small increase in risk with budesonide-containing treatment cannot be ruled out; there is considerable heterogeneity in study designs and patient characteristics, particularly in the early budesonide studies, and each study contributes <40 pneumonia TESAEs.
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Affiliation(s)
- Sally Hollis
- AstraZeneca R&D, Alderley Park, Macclesfield, UK
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Morjaria JB, Rigby A, Morice AH. Inhaled Corticosteroid use and the Risk of Pneumonia and COPD Exacerbations in the UPLIFT Study. Lung 2017; 195:281-288. [PMID: 28255905 PMCID: PMC5437199 DOI: 10.1007/s00408-017-9990-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/20/2017] [Indexed: 01/18/2023]
Abstract
RATIONALE Unlike many other COPD studies, the 4-year UPLIFT trial permitted inhaled corticosteroid (ICS) use during run-in and treatment phases. This provided the opportunity to prospectively observe the continuing effects of ICS on respiratory events in closely observed COPD population. OBJECTIVES We aimed to determine rate and number of episodes of pneumonia and exacerbations of COPD in patients entering the study on no ICS, fluticasone proprionate (FP), and other ICS. METHODS The UPLIFT dataset was examined retrospectively, and patients were divided into three groups based on their medications at entry: no ICS, FP and other ICS. Poisson regression was used to compare the frequency of respiratory adverse events. MEASUREMENTS AND MAIN RESULTS At entry, the groups were well matched apart from a higher FEV1% predicted (38 vs. 41%; ICS vs. no ICS, respectively) and prevalence of current smoking (26 vs. 36%; ICS vs. no ICS, respectively). Incidence rates of pneumonia were significantly higher in patients taking ICS compared to no ICS (0.068 vs. 0.056 respectively; p = 0.012). When the FP group was compared to the other ICS, the event rate was even higher (0.077 vs. 0.058, respectively; p < 0.001). COPD exacerbations were more frequent in patients taking ICS, with significantly greater rate in the FP group compared to that seen with other ICS (0.93 vs. 0.84 respectively; p = 0.013). CONCLUSIONS ICS use was associated an increase in respiratory adverse event rates, but whether this was due to more severe illness at entry is unknown. In subgroup analysis, the excess of morbidity in the ICS group appeared to be mainly associated with those receiving FP at randomisation.
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Affiliation(s)
- Jaymin B Morjaria
- Centre for Cardiovascular & Metabolic Research, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, HU6 5JQ, UK.,Department of Respiratory Medicine, Royal Brompton & Harefield NHS Trust, Harefield Hospital, Hill End road, Harefield, UB9 6JH, UK
| | - Alan Rigby
- Centre for Cardiovascular & Metabolic Research, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, HU6 5JQ, UK
| | - Alyn H Morice
- Centre for Cardiovascular & Metabolic Research, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, HU6 5JQ, UK.
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Koch A, Kreutzer K, von Oldershausen G, Poets CF, Bassler D. Inhaled Glucocorticoids and Pneumonia in Preterm Infants: Post Hoc Results from the NEuroSIS Trial. Neonatology 2017; 112:110-113. [PMID: 28456800 DOI: 10.1159/000468507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inhaled glucocorticoids may increase the risk of pneumonia in adults. Thus, respiratory infections may be a potential explanation for the non-significantly increased mortality seen in the glucocorticoid group in the largest randomized trial on inhaled glucocorticoids for preventing bronchopulmonary dysplasia in preterm infants published to date (NEuroSIS). OBJECTIVE To evaluate the effect of inhaled budesonide on the risk of death due to respiratory infections in the NEuroSIS trial. METHODS We performed post hoc analyses of prospectively collected data from 856 preterm infants on presumed but not culture-proven sepsis and antimicrobial drug use. Additionally, pulmonary complications reported on adverse event forms, death certificates and autopsy reports were compared between study groups. RESULTS Treatment groups did not differ in the number of episodes with suspected sepsis (184/437 [42.1%] in the budesonide vs. 171/419 [40.8%] in the placebo group). Neither the number of patients receiving antimicrobial drugs nor the length of antimicrobial treatment differed between groups. Our analyses for pulmonary adverse events as well as for pulmonary complications reported on death certificates and autopsy reports did not suggest a negative impact of inhaled budesonide on these outcomes. CONCLUSION The current analysis does not support the assumption that respiratory tract infections explain the increased mortality seen in the glucocorticoid group in the NEuroSIS trial.
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Affiliation(s)
- Alexander Koch
- Department of Neonatology, University Childrens' Hospital Tuebingen, Tuebingen, Germany
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Wang CY, Lai CC, Yang WC, Lin CC, Chen L, Wang HC, Yu CJ. The association between inhaled corticosteroid and pneumonia in COPD patients: the improvement of patients' life quality with COPD in Taiwan (IMPACT) study. Int J Chron Obstruct Pulmon Dis 2016; 11:2775-2783. [PMID: 27877031 PMCID: PMC5108503 DOI: 10.2147/copd.s116750] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
To investigate the association between inhaled corticosteroid (ICS) exposure patterns and the risk of pneumonia in chronic obstructive pulmonary disease (COPD) patients, we performed a nested case-control study. Between 1998 and 2010, 51,739 patients, including 19,838 cases of pneumonia, were matched to 74,849 control subjects selected from a cohort of COPD patients using ICSs via risk-set sampling of the database constructed by the National Health Research Institutes of Taiwan. After adjusting for covariates, the current use of ICSs was associated with a 25% increase in the risk of pneumonia (odds ratio [OR] =1.25, 95% confidence interval [CI] =1.20–1.30), and there was an increase in the OR with increase in the average daily dosage. Additionally, users of fluticasone/salmeterol, fluticasone, and either fluticasone/salmeterol or fluticasone were more likely to be at a higher risk of pneumonia (OR =1.35, 95% CI =1.28–1.41; OR =1.22, 95% CI =1.10–1.35; and OR =1.33, 95% CI =1.27–1.39, respectively). In contrast, there were no statistically significant associations between the risk of pneumonia and the use of budesonide/formoterol, budesonide, or either budesonide/formoterol or budesonide. In conclusion, ICSs are significantly associated with an increased risk of pneumonia in COPD patients. The effect is prominent for fluticasone-containing ICSs but not for budesonide-containing ICSs.
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Affiliation(s)
- Cheng-Yi Wang
- Department of Internal Medicine; Medical Research Center, Cardinal Tien Hospital, Fu Jen Catholic University College of Medicine, New Taipei City
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying
| | - Wei-Chih Yang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan
| | - Chia-Chieh Lin
- Department of Internal Medicine; Medical Research Center, Cardinal Tien Hospital, Fu Jen Catholic University College of Medicine, New Taipei City
| | - Likwang Chen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
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Yawn BP, Suissa S, Rossi A. Appropriate use of inhaled corticosteroids in COPD: the candidates for safe withdrawal. NPJ Prim Care Respir Med 2016; 26:16068. [PMID: 27684954 PMCID: PMC5042192 DOI: 10.1038/npjpcrm.2016.68] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 07/11/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023] Open
Abstract
International guidance on chronic obstructive pulmonary disease (COPD) management recommends the use of inhaled corticosteroids (ICS) in those patients at increased likelihood of exacerbation. In spite of this guidance, ICS are prescribed in a large number of patients who are unlikely to benefit. Given the evidence of the risks associated with ICS and the limited indications for their use, there is interest in understanding the effects of withdrawing ICS when prescribed inappropriately. In this review, we discuss the findings of large ICS withdrawal trials, with primary focus on the more recent trials using active comparators. Data from these trials indicate that ICS may be withdrawn without adverse impact on exacerbation risk and patient-reported outcomes in patients with moderate COPD and no history of frequent exacerbations. Considering the safety concerns associated with ICS use, these medications should be withdrawn in patients for whom they are not recommended, while maintaining adequate bronchodilator therapy.
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Affiliation(s)
- Barbara P Yawn
- Department of Family and Community Health, University of Minnesota, Rochester, MN, USA
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Department of Epidemiology and Biostatistics and Department of Medicine, McGill University, Montreal, QC, Canada
| | - Andrea Rossi
- Pulmonary Unit, University and General Hospital, Verona, Italy
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