Exacerbations, health services utilization, and costs in commercially-insured COPD patients treated with nebulized long-acting β2-agonists

OBJECTIVE

This retrospective cohort study compared exacerbations, health services utilization, and costs among chronic obstructive pulmonary disease (COPD) patients who received nebulized arformoterol or nebulized formoterol therapy.

METHODS

Using PharMetrics Plus health plan claims, 417 nebulized long-acting β2-agonist (LABA) users meeting the study inclusion criteria were identified: had ≥2 fills of nebulized arformoterol or nebulized formoterol from January 1, 2009, to December 31, 2011, adhered to using their index drug ≥60% of the days during 1 year post-index, were ≥35 years old and continuously enrolled 180 days pre- and 1 year post-index, and did not use a nebulized LABA or have an asthma diagnosis during the pre-index period. Descriptive and multivariate analyses were performed.

RESULTS

A total of 274 nebulized arformoterol users and 143 nebulized formoterol users were identified with comparable demographic characteristics. However, significant differences were observed between the two groups in some clinical characteristics at index including comorbidities and use of antibiotics. At 1 year post-index, a lower proportion of nebulized arformoterol users had ≥1 exacerbation compared to nebulized formoterol users (70.4% vs 80.4%; p = 0.028). Among patients with ≥1 hospital admission, COPD-related costs per inpatient stay were significantly lower for nebulized arformoterol users than nebulized formoterol users (median = $9542 vs $14,025; p = 0.009). After controlling for confounders, nebulized arformoterol users had 19% marginally lower risk of exacerbations than nebulized formoterol users (hazard ratio = 0.81, 95% confidence interval = 0.64-1.03; p < 0.084) and 14.4% marginally lower COPD-related total costs at 1 year post-index (p = 0.062), primarily related to fewer hospital readmissions (7.6% vs 12.2%) and lower average costs per readmission stay (median = $7392 vs $18 081; p = 0.006).

CONCLUSIONS

This study suggests that the choice of nebulized LABA may influence COPD-related exacerbation occurrence and costs. Future studies with larger and more closely matched nebulized arformoterol and nebulized formoterol users are needed to confirm these findings.

Review of drug safety and efficacy of arformoterol in chronic obstructive pulmonary disease

INTRODUCTION

The global initiative for chronic obstructive lung disease guidelines recommend maintenance therapy using long-acting bronchodilators for patients with chronic obstructive pulmonary disease (COPD) who have daily symptoms. Arformoterol is the (R, R) - enantiomer of the racemic formoterol and is more potent than (R, R/ S, S) - formoterol.

AREAS COVERED

Currently, arformoterol is one of two nebulized long-acting β-agonists on the market. It has a low incidence of cardiovascular side effects with incidence of arrhythmia and ischemia similar to placebo. β-adrenergic adverse effects are infrequent, numerically lower than formoterol, but have a quicker onset of action than salmeterol. There was no observed clinical tolerance over 12 months. arformoterol is safe in combination therapy with inhaled corticosteroids, tiotropium and rescue inhalers. A 12-month Phase IV trial found no increased risk of respiratory death or COPD exacerbation-related hospitalizations. arformoterol can potentially benefit patients with hyperinflation and low inspiratory flow rates.

EXPERT OPINION

The introduction of the centers for medicare and medicaid services penalization for COPD readmissions may boost the appeal of long-acting bronchodilators as new discharge medications. With the advent of ultra long-acting bronchodilators, its potential as a once daily agent in isolation or combination with these new therapies needs further study.

One-year safety and efficacy study of arformoterol tartrate in patients with moderate to severe COPD

BACKGROUND

Arformoterol tartrate (arformoterol, 15 μg bid) is a nebulized long-acting β2-agonist approved for maintenance treatment of COPD.

METHODS

This was a multicenter, double-blind, randomized, placebo-controlled study. Patients (aged ≥ 40 years with baseline FEV1 ≤ 65% predicted, FEV1 > 0.50 L, FEV1/FVC ≤ 70%, and ≥ 15 pack-year smoking history) received arformoterol (n = 420) or placebo (n = 421) for 1 year. The primary assessment was time from randomization to respiratory death or first COPD exacerbation-related hospitalization.

RESULTS

Among 841 patients randomized, 103 had ≥ 1 primary event (9.5% vs 15.0%, for arformoterol vs placebo, respectively). Patients who discontinued treatment for any reason (39.3% vs 49.9%, for arformoterol vs placebo, respectively) were followed for up to 1 year postrandomization to assess for primary events. Fewer patients receiving arformoterol than placebo experienced COPD exacerbation-related hospitalizations (9.0% vs 14.3%, respectively). Twelve patients (2.9%) receiving arformoterol and 10 patients (2.4%) receiving placebo died during the study. Risk for first respiratory serious adverse event was 50% lower with arformoterol than placebo (P = .003). Numerically more patients on arformoterol (13; 3.1%) than placebo (10; 2.4%) experienced cardiac serious adverse events; however, time-to-first cardiac serious adverse event was not significantly different. Improvements in trough FEV1 and FVC were greater with arformoterol (least-squares mean change from baseline vs placebo: 0.051 L, P = .030 and 0.075 L, P = .018, respectively). Significant improvements in quality of life (overall St. George's Hospital Respiratory Questionnaire and Clinical COPD Questionnaire) were observed with arformoterol vs placebo (P < .05).

CONCLUSIONS

Arformoterol demonstrated an approximately 40% lower risk of respiratory death or COPD exacerbation-related hospitalization over 1 year vs placebo. Arformoterol was well-tolerated and improved lung function vs placebo.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00909779; URL: www.clinicaltrials.gov.

Pharmacology and therapeutics of bronchodilators

Bronchodilators are central in the treatment of of airways disorders. They are the mainstay of the current management of chronic obstructive pulmonary disease (COPD) and are critical in the symptomatic management of asthma, although controversies around the use of these drugs remain. Bronchodilators work through their direct relaxation effect on airway smooth muscle cells. at present, three major classes of bronchodilators, β(2)-adrenoceptor (AR) agonists, muscarinic receptor antagonists, and xanthines are available and can be used individually or in combination. The use of the inhaled route is currently preferred to minimize systemic effects. Fast- and short-acting agents are best used for rescue of symptoms, whereas long-acting agents are best used for maintenance therapy. It has proven difficult to discover novel classes of bronchodilator drugs, although potential new targets are emerging. Consequently, the logical approach has been to improve the existing bronchodilators, although several novel broncholytic classes are under development. An important step in simplifying asthma and COPD management and improving adherence with prescribed therapy is to reduce the dose frequency to the minimum necessary to maintain disease control. Therefore, the incorporation of once-daily dose administration is an important strategy to improve adherence. Several once-daily β(2)-AR agonists or ultra-long-acting β(2)-AR-agonists (LABAs), such as indacaterol, olodaterol, and vilanterol, are already in the market or under development for the treatment of COPD and asthma, but current recommendations suggest the use of LABAs only in combination with an inhaled corticosteroid. In addition, some new potentially long-acting antimuscarinic agents, such as glycopyrronium bromide (NVA-237), aclidinium bromide, and umeclidinium bromide (GSK573719), are under development, as well as combinations of several classes of long-acting bronchodilator drugs, in an attempt to simplify treatment regimens as much as possible. This review will describe the pharmacology and therapeutics of old, new, and emerging classes of bronchodilator.

Third-generation long-acting β₂-adrenoceptor agonists: medicinal chemistry strategies employed in the identification of once-daily inhaled β₂-adrenoceptor agonists

Inhaled long-acting β(2)-adrenoceptor agonists (LABAs) are highly effective bronchodilators in the treatment of asthma and chronic obstructive pulmonary disease. There is significant interest in the development of third-generation compounds that improve upon the marketed twice-daily LABAs salmeterol and formoterol. A principal advantage sought from the next generation is duration of action that supports once-daily dosing, although improved efficacy, faster onset, and increased therapeutic index are also frequently cited as objectives. Recent publications detailing medicinal chemistry programs directed at the discovery of third-generation LABAs illustrate a wide variety of strategies that have been successfully employed towards these goals. Some recent scientific advances in the understanding of inhaled bronchodilators are discussed and the reported medicinal chemistry strategies are reviewed in the context of these advances.