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Wang X, Wang T, Chen X, Tian W, Ma D, Zhang J, Li Q, Chen Z, Ju J, Xu H, Chen K. Efficacy and Safety of Oral Anticoagulants in Older Adult Patients With Atrial Fibrillation: Pairwise and Network Meta-Analyses. J Am Med Dir Assoc 2023:S1525-8610(23)00474-7. [PMID: 37355246 DOI: 10.1016/j.jamda.2023.05.010] [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: 01/17/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of oral anticoagulants for older adult patients with atrial fibrillation (AF). DESIGN Pairwise and network meta-analyses. SETTING AND PARTICIPANTS Patients with AF aged ≥75 years. METHODS PubMed, Embase, and the Cochrane library were searched for published randomized controlled trials and adjusted observational studies evaluating the use of a non-vitamin K antagonist oral anticoagulants (NOACs), vitamin K antagonist, or antiplatelet drug for the prevention of stroke. The primary efficacy and safety outcomes were the composite of stroke and systemic embolism (SSE) and major bleedings. RESULTS This study included 38 studies enrolling 1,022,908 older adult patients with AF. Results from pairwise meta-analyses showed that NOACs were superior to warfarin for all outcomes, except that dabigatran increased the risk of gastrointestinal (GI) bleedings. Aspirin was associated with a higher risk of SSE and ischemic stroke than warfarin or NOACs. Results of network meta-analyses indicated that apixaban significantly reduced the risk of SSE, major bleedings, and GI bleedings than warfarin, rivaroxaban, and dabigatran. Apixaban, edoxaban, rivaroxaban, and dabigatran reduced the risk of ischemic stroke and intracranial bleeding compared to warfarin. Dabigatran showed lower risk of all-cause mortality than warfarin and of intracranial bleeding than rivaroxaban. CONCLUSIONS AND IMPLICATIONS NOACs are of at least equal efficacy, or even superior to warfarin. The safety profile of individual NOAC agents was significantly different, as apixaban performs better than the other oral anticoagulants in reducing major bleeding and GI bleeding, whereas dabigatran increased the risk of GI bleeding.
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Affiliation(s)
- Xinyi Wang
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Tongxin Wang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xuanye Chen
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Wende Tian
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dan Ma
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jie Zhang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Qiuyi Li
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Zhuo Chen
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianqing Ju
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hao Xu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Keji Chen
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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Bakerly ND, Nikitin K, Snowise NG, Cardwell G, Freeman D, Saggu R, De Soyza A. Pragmatic randomised controlled trials in COPD and asthma: how to guide clinical practice. BMJ Open Respir Res 2022; 9:9/1/e001303. [PMID: 36180103 PMCID: PMC9528570 DOI: 10.1136/bmjresp-2022-001303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022] Open
Abstract
The use of real-world evidence (RWE) studies, including pragmatic randomised controlled trials (RCTs; randomised RWE studies), to aid the development of treatment guidelines, is gradually becoming a mainstay within clinical practice. RWE is an integral part of patient-driven decision-making and offers important value to add complimentary evidence to traditional RCTs; these provide a more well-rounded view of the benefits to patient-reported outcomes and improve the external validity of a given treatment versus findings from traditional RCTs alone. Discussions in recent scientific workshops explored the importance of pragmatic RCTs in optimising guideline development and patient care in chronic obstructive pulmonary disease (COPD) and asthma. The Salford Lung Study in patients with COPD (NCT01551758) and asthma (NCT01706198) were the world’s first prelicence pragmatic RCTs that compared novel investigational treatments with existing COPD and asthma treatments and, more recently (2021), RWE studies have been used by the American Thoracic Society and the US Food and Drug Administration to support the approval of an immunosuppressant drug in patients receiving lung transplants. This highlights the importance of RWE data in supporting clinical guideline development and emphasises the advantages for the use of pragmatic RCTs in guiding clinical practice.
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Affiliation(s)
- Nawar Diar Bakerly
- School of Biological Sciences, Manchester Metropolitan University, Manchester, UK.,Salford Royal, NHS Foundation Trust, Salford, UK
| | | | - Neil G Snowise
- Institute of Pharmaceutical Science, Faculty of Life Sciences and Medicine, King's College, London, UK
| | | | - Daryl Freeman
- Norfolk Community Health and Care, Woodlands House, Norwich, UK
| | - Ravijyot Saggu
- Pharmacy Department, University College Hospital, NHS Foundation Trust, London, UK
| | - Anthony De Soyza
- Population and Health Sciences Institute, Newcastle University, Newcastle, UK
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3
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Rogliani P, Ritondo BL, Zerillo B, Cazzola M, Matera MG, Calzetta L. Adding a Second Bronchodilator in COPD: A Meta-Analysis on the Risk of Specific Cardiovascular Serious Adverse Events of Tiotropium/Olodaterol Fixed-Dose Combination. COPD 2020; 17:215-223. [PMID: 32252547 DOI: 10.1080/15412555.2020.1749252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Dual bronchodilation therapy represents the cornerstone for the treatment of COPD. A large retrospective study reports that adding a second long-acting bronchodilator in patients with COPD significantly increases the risk of heart failure. Nevertheless, retrospective studies are characterized by limitations including misdiagnosis and inaccuracy of recordkeeping. This study aimed to ascertain whether tiotropium/olodaterol (T/O) 5/5 μg fixed-dose combination (FDC) may modulate the risk of main cardiovascular outcomes in COPD patients enrolled in randomized controlled trials (RCTs). A meta-analysis (CRD42017070100) was performed by selecting RCTs reporting raw data from the ClinicalTrials.gov database concerning the impact of T/O 5/5 µg FDC vs. monocomponents on the occurrence of specific cardiovascular serious adverse events: arrhythmia, heart failure, myocardial infarction, and stroke. Data were reported as relative risk and 95% Confidence Interval, and the risk of publication bias assessed via Egger's test. Eighty six full text articles were identified, and 10 RCTs published in 7 studies between 2015 and 2018 were included into the analysis. Data obtained from 12,690 COPD patients (44.47% T/O FDC, 55.53% monocomponents) were extracted. T/O 5/5 μg FDCs did not significantly modulate (p-value > 0.05) the risk of arrhythmia (1.02, 0.55 - 1.92), heart failure (0.88, 0.41 - 1.92), myocardial infarction (1.15, 0.70 - 1.87), and stroke (0.98, 0.44 - 2.16) vs. monocomponents. No significant publication bias affected the effect estimates of this meta-analysis. The results of this quantitative synthesis indicate that dual bronchodilation with T/O 5/5 μg FDC is characterized by an acceptable cardiovascular safety profile in COPD patients.
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Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata", Rome, Italy
| | - Beatrice Ludovica Ritondo
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Bartolomeo Zerillo
- Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata", Rome, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigino Calzetta
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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4
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Calzetta L, Ritondo BL, Matera MG, Cazzola M, Rogliani P. Evaluation of fluticasone propionate/salmeterol for the treatment of COPD: a systematic review. Expert Rev Respir Med 2020; 14:621-635. [PMID: 32168461 DOI: 10.1080/17476348.2020.1743180] [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] [Indexed: 12/30/2022]
Abstract
Introduction: Recently, the generic formulation of FP/SAL FDC has been approved in COPD. Although FP/SAL FDC has been the first long-acting FDC approved in COPD, no systematic review assessed the effect of this combination for the treatment of COPD by considering specifically Phase IV studies. The aim of this review was to systematically assess the effect of FP/SAL FDC in COPD patients enrolled in Phase IV studies.Areas covered: The question of this systematic review was to examine the evidence regarding the impact of FP/SAL FDC for the treatment of COPD by searching for Phase IV studies in the ClinicalTrials.gov database.Expert opinion: Generic drugs represent an effective cost-saving step for health-care budgets in the treatment of COPD and should be used in agreement with current recommendations and prescription accuracy. FP/SAL FDC is recommended for the initiation therapy just in a small percentage of symptomatic patients that are at high risk of exacerbation with blood eosinophil counts ≥300 cells per μl. At follow-up, FP/SAL FDC can be escalated to triple ICS/LABA/LAMA combination or switched to LABA/LAMA combination by considering symptoms, exacerbations, lack of response to ICS, inappropriate original indication, and ICS-related adverse events such as pneumonia.
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Affiliation(s)
- Luigino Calzetta
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | | | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Leather DA, Jones R, Woodcock A, Vestbo J, Jacques L, Thomas M. Real-World Data and Randomised Controlled Trials: The Salford Lung Study. Adv Ther 2020; 37:977-997. [PMID: 31927698 PMCID: PMC7147238 DOI: 10.1007/s12325-019-01192-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Indexed: 01/31/2023]
Abstract
Traditional efficacy double-blind randomised controlled trials (DBRCTs) measure the benefit a treatment produces under near-ideal test conditions in highly selected patient populations; however, the behaviour of patients and investigators in such trials is highly controlled, highly compliant and adherent, and non-representative of routine clinical practice. Pragmatic effectiveness trials measure the benefit a treatment produces in patients in everyday "real-world" practice. Ideally, effectiveness trials should recruit patients as similar as possible to those who will ultimately be prescribed the medicine, and create freedom within the study design to allow normal behaviours of patients and healthcare professionals (HCPs) to be expressed. The Salford Lung Study (SLS) was a world-first, prospective, phase III, pragmatic randomised controlled trial (RCT) programme in patients with chronic obstructive pulmonary disease and asthma to evaluate the effectiveness of a pre-licensed medication (fluticasone furoate/vilanterol) in real-world practice using electronic health records and through collaboratively engaging general practitioners and community pharmacists in clinical research. The real-world aspect of SLS was unique, requiring careful planning and attention to the goals of maximising the external validity of the trials while maintaining scientific rigour and securing suitable electronic processes for proper interpretation of safety data. Key learnings from SLS that may inform the design of future pragmatic effectiveness RCTs include: (1) ensuring the trial setting and operational infrastructure are aligned with routine clinical care; (2) recruiting a broad patient population with characteristics as close as possible to patients in routine clinical practice, to maximise the generalisability and applicability of trial results; (3) ensuring that patients and HCPs are suitably engaged in the trial, to maximise the chances of successful trial delivery; and (4) careful study design, incorporating outcomes of value to patients, HCPs, policymakers and payers, and using pre-planned analyses to address scientifically valid research hypotheses to ensure robustness of the trial data.
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Affiliation(s)
- David A Leather
- Global Respiratory Franchise, GlaxoSmithKline plc., Brentford, Middlesex, UK.
| | - Rupert Jones
- Community and Primary Health Care, Faculty of Health, Plymouth University, Plymouth, UK
| | - Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Sciences Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Sciences Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Loretta Jacques
- Clinical Sciences, GlaxoSmithKline plc., Uxbridge, Middlesex, UK
| | - Mike Thomas
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
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6
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Zhang J, Tang J, Cui X, Wang B, Bu M, Bai Y, Wang K, Guo J, Shen D, Zhang J. Indirect comparison of novel Oral anticoagulants among Asians with non-Valvular atrial fibrillation in the real world setting: a network meta-analysis. BMC Cardiovasc Disord 2019; 19:182. [PMID: 31366374 PMCID: PMC6670242 DOI: 10.1186/s12872-019-1165-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 07/19/2019] [Indexed: 12/12/2022] Open
Abstract
Background The development of novel oral anticoagulants (NOACs) has changed the landscape of non-valvular atrial fibrillation (NVAF) management. In this study, the effectiveness and the safety of several NOACs were evaluated in a real-world setting among Asian patients with NVAF. Methods The literature search was conducted crossing different databases including Embase, MEDLINE, and the Cochrane Library from inception through March 1, 2019, for studies which included real-world perspectives comparing the individual NOACs with each other or with warfarin among Asians with NVAF. The primary outcomes were defined as stroke or systemic embolism (SSE) and major bleeding; ischemic stroke, all-cause death as well as intracranial bleeding were classified as the secondary outcomes. Results From sixteen real-world studies, a total of 312,827 Asian patients were included in this analysis. In comparison with warfarin, the utilization of apixaban, dabigatran, and rivaroxaban significantly lowered the risk of major bleeding (apixaban: HR 0.47, 95%CI 0.35–0.63; dabigatran: HR 0.59, 95%CI 0.47–0.73; rivaroxaban: HR 0.66, 95%CI 0.52–0.83) and lessened the all-cause death rate (apixaban: HR 0.29, 95%CI 0.16–0.52; dabigatran: HR 0.40, 95%CI 0.27–0.60; rivaroxaban: HR 0.42, 95%CI 0.28–0.65). Apixaban (HR 0.59; 95%CI 0.40–0.85) reduced the possibility of ischemic stroke when compared against dabigatran. Rivaroxaban showed a higher chance of causing an ischemic stroke (HR 1.61; 95%CI 1.08–2.41) and major bleeding (HR 1.39; 95%CI 1.02–1.90) than Apixaban. Conclusions Apixaban, dabigatran and rivaroxaban were more effective than warfarin on reducing the risks of stroke and haemorrhage; meanwhile, apixaban was likely to lower the risk of major bleeding comparing to rivaroxaban. Trial registration PROSPERO registry number: CRD42018086914. Electronic supplementary material The online version of this article (10.1186/s12872-019-1165-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jianchao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Junnan Tang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China. .,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China.
| | - Xiaolin Cui
- Department of Orthopaedic Surgery, University of Otago, Christchurch, 8011, New Zealand
| | - Bo Wang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Mengsen Bu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Yan Bai
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Kai Wang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Jiacheng Guo
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Deliang Shen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Jinying Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China. .,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China.
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7
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Wang MT, Lai JH, Tsai CL, Liou JT. Risk of adverse cardiovascular events with use of inhaled long-acting bronchodilators in management of chronic obstructive pulmonary disease. J Food Drug Anal 2019; 27:657-670. [PMID: 31324282 PMCID: PMC9307027 DOI: 10.1016/j.jfda.2018.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 01/01/2023] Open
Abstract
Inhaled long-acting bronchodilators, including long-acting β2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) are the mainstay therapy in the treatment of chronic obstructive pulmonary disease (COPD), a disease that poses a heavy burden on morbidity and mortality worldwide. Use of LABAs and LAMAs in patients with COPD, however, has been concerned about an increased risk of adverse cardiovascular events, despite inconsistent findings reported from randomized controlled trials (RCTs) and observational studies. In this review, we detailed the relevant evidence generated from RCTs and observational studies with respect to the risk of cardiovascular disease with use of LABAs and LAMAs in management of COPD, and analyzed the contradictory findings in the literature, as well as recommended future research directions to clear the air regarding the cardiovascular safety of inhaled long-acting bronchodilators.
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Affiliation(s)
- Meng-Ting Wang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan.
| | - Jyun-Heng Lai
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan.
| | - Chen-Liang Tsai
- Division of Pulmonary and Critical Care, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| | - Jun-Ting Liou
- Division of Cardiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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8
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Ferguson GT, Tosiello R, Sanjar S, Goodin T. Efficacy and Safety of Nebulized Glycopyrrolate/eFlow® Closed System in Patients with Moderate-to-Very-Severe Chronic Obstructive Pulmonary Disease with Pre-Existing Cardiovascular Risk Factors. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 6:86-99. [PMID: 30775427 DOI: 10.15326/jcopdf.6.1.2018.0146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Purpose: The purpose of this study was to assess the effect of pre-existing cardiovascular (CV) risk factors on the efficacy and safety of nebulized glycopyrrolate (GLY) in patients with chronic obstructive pulmonary disease (COPD). Methods: A total of 2379 patients from 3 phase III studies (12-week, placebo-controlled Glycopyrrolate for Obstructive Lung Disease via Electronic Nebulizer [GOLDEN] -3 and -4, and 48-week, active-controlled GOLDEN-5) stratified by high (n=1526) or low (n=853) CV risk were randomized to placebo, GLY 25 mcg or 50 mcg twice daily, or tiotropium (TIO; 18 mcg once daily). Safety, lung function, patient-reported outcomes (PROs), and exacerbations were assessed by CV risk. Results: Treatment-emergent adverse events (TEAEs) were similar across CV risk subgroups, with serious TEAEs higher in the high CV risk subgroup. In the 12-week studies, discontinuation due to TEAEs with GLY 25 mcg and 50 mcg was similar between CV risk subgroups, and lower than placebo (high risk: 6.2%, 3.6%, 9.0%; low risk: 3.2%, 4.5%, 9.9%, respectively). In the 48-week, open-label study, discontinuation rates were higher with GLY versus TIO (high risk: 10.7%, 3.7%; low risk: 8.7%, 1.2%, respectively). Rates of CV events of special interest were similar across CV risk subgroups. Regardless of CV risk, GLY led to significant improvements in efficacy and PRO assessments at 12 weeks versus placebo, whereas changes were similar between GLY and TIO at 48 weeks, except for PROs in the low risk subgroup. Exacerbation rates were similar across all treatment groups. Conclusions: Nebulized GLY had an acceptable safety profile and improved lung function and PROs in COPD patients, irrespective of CV risk status.
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Affiliation(s)
- Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills
| | | | - Shahin Sanjar
- Sunovion Pharmaceuticals Inc., Marlborough, Massachusetts
| | - Thomas Goodin
- Sunovion Pharmaceuticals Inc., Marlborough, Massachusetts
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9
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Rabe KF, Hurst JR, Suissa S. Cardiovascular disease and COPD: dangerous liaisons? Eur Respir Rev 2018; 27:27/149/180057. [PMID: 30282634 DOI: 10.1183/16000617.0057-2018] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β2-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.
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Affiliation(s)
- Klaus F Rabe
- Dept of Medicine, University of Kiel, Kiel, Germany .,Lung Clinic Großhansdorf, Airway Research Center North (ARCN), Groβhansdorf, Germany
| | - John R Hurst
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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10
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Russell REK. What Does the TOVITO Programme Tell Us about How We Can Manage COPD? Turk Thorac J 2018; 19:216-219. [PMID: 30455993 DOI: 10.5152/turkthoracj.2018.182609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 11/22/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) patients suffer from a significant burden of disease which impairs their quality of life, exercise capacity and lung function. They also suffer from acute worsening of disease, called exacerbations. The role of drug treatment in the management of COPD is aimed at improving lung function, quality of life and reducing the risk of exacerbations. Bronchodilator drugs are the mainstay of therapy and the tow classes, long acting beta2 agonists and long acting anti-muscarinics, are being combined together. The TOVITO programme of clinical research is a comprehensive and consistent set of studies investigating the role of Tiotropium and Olodaterol (Spiolto) on lung function, quality of life, exercise capacity and exacerbation frequency. The programme has included over 16 000 patients who have received the benefits of these two compounds when given together in a suitable inhaler. Safety data was collected with a focus on cardiovascular morbidity and mortality. The use of tiotropium/olodaterol combination resulted in significant gains in lung function, quality of life and exercise endurance. There was no difference between the arms in the Dynagito study which was designed to compare tiotropium/olodaterol combination with its constituent compounds. In all studies no safety concerns were raised. Tiotropium/Olodaterol (Spiolto) is an effective treatment for COPD with benefits to lung function, quality of life and exercise tolerance.
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Affiliation(s)
- Richard E K Russell
- Senior Clinical Researcher, Respiratory Medicine, Nuffield Department of Medicine, University of Oxford. Consultant Chest Physician, Lymington New Forest Hospital, Southern Health NHS Foundation Trust, Oxford, United Kingdom
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11
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Kerwin EM, Tosiello R, Price B, Sanjar S, Goodin T. Effect of background long-acting beta 2-agonist therapy on the efficacy and safety of a novel, nebulized glycopyrrolate in subjects with moderate-to-very-severe COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:2917-2929. [PMID: 30275690 PMCID: PMC6157543 DOI: 10.2147/copd.s172408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Phase III studies demonstrated efficacy and safety of nebulized glycopyrrolate inhalation solution (GLY) in subjects with COPD. Secondary analyses were performed to examine the effect of background long-acting beta2-agonist (LABA) use on the efficacy and safety of nebulized GLY. Methods In two 12-week placebo-controlled studies (GOLDEN 3 and GOLDEN 4) and one 48-week, open-label active-controlled study (GOLDEN 5), a total of 2,379 subjects were stratified by background LABA use (LABA-yes: n=861; LABA-no: n=1,518) and randomized to placebo vs GLY 25 or 50 µg twice daily, or GLY 50 µg twice daily vs tiotropium (TIO) 18 µg once daily. Lung function, patient-reported outcomes, exacerbations, and safety were assessed. Results Compared with placebo, pooled data from the 12-week studies showed significant improvements from baseline with GLY 25 and 50 µg across LABA subgroups in trough FEV1 (LABA-yes: 0.101 and 0.110 L; LABA-no: 0.092 and 0.101 L, respectively; P<0.001) and St George’s Respiratory Questionnaire total score (SGRQ; LABA-yes: −2.957 and −3.888; LABA-no: −3.301 and −2.073, respectively; P<0.05). Incidence of treatment-emergent adverse events (TEAEs) was similar in LABA subgroups, and lower in GLY 25 µg vs placebo. In the 48-week active-controlled study, GLY and TIO both showed improvement from baseline across LABA subgroups in FEV1 (LABA-yes: 0.106 and 0.092 L; LABA-no: 0.096 and 0.096 L, respectively) and in SGRQ total score (LABA-yes: −5.190 and −3.094; LABA-no: −4.368 and −4.821, respectively). Incidence of TEAEs was similar between GLY and TIO, and across LABA subgroups. Exacerbation rates were similar across treatments and LABA subgroups, and cardiovascular events of special interest were more frequent in the LABA-no subgroup. Nebulized GLY, combined with LABA, did not generate any additional safety signals. Conclusion Nebulized GLY demonstrated efficacy and was well tolerated up to 48 weeks in subjects with COPD with/without background LABA.
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Affiliation(s)
- Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Inc., Medford, OR, USA,
| | | | - Barry Price
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
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12
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Singh D. Single inhaler triple therapy with extrafine beclomethasone, formoterol, and glycopyrronium for the treatment of chronic obstructive pulmonary disease. Expert Opin Pharmacother 2018; 19:1279-1287. [PMID: 29985096 DOI: 10.1080/14656566.2018.1498841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) management focuses on the alleviation of symptoms and prevention of exacerbations. Inhaled long acting bronchodilators and inhaled corticosteroids (ICS) are the main classes of treatment for COPD. Triple therapy with a long acting beta2-agonist (LABA), long acting muscarinic antagonist (LAMA), and ICS is commonly prescribed for symptomatic COPD patients experiencing regular exacerbations. Triple therapy is usually administered using separate inhalers; there is little clinical trial evidence of an effect on exacerbation prevention with this approach. Areas covered: This evaluation reviews the single inhaler extrafine combination containing beclometasone diproprionate (BDP), formoterol fumarate (FF), and glycopyrronium bromide (GB) which has been developed as a simplified triple regime. BDP/FF/GB significantly reduced exacerbation rates in three clinical trials (1-year duration) compared against LAMA monotherapy (20% exacerbation reduction), ICS/LABA combination (23% exacerbation reduction), and LAMA/LABA combination (15% exacerbation reduction). Expert opinion: The practical benefits of single inhaler triple therapy in the real world have not been studied. However, the robust clinical trial evidence that BDP/FF/GB reduces exacerbations compared to double combination treatments and LAMA monotherapy cements triple therapy positioning as an escalation step in COPD management pathways.
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Affiliation(s)
- Dave Singh
- a University of Manchester, Medicines Evaluation Unit, The Langley Building, Manchester University NHS Foundation Hospital Trust , Manchester , UK
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13
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Tonin FS, Steimbach LM, Leonart LP, Ferreira VL, Borba HH, Piazza T, Araújo AG, Fernandez-Llimos F, Pontarolo R, Wiens A. Discontinuation of non-anti-TNF drugs for rheumatoid arthritis in interventional versus observational studies: a systematic review and meta-analysis. Eur J Clin Pharmacol 2018; 74:1513-1521. [PMID: 30022333 DOI: 10.1007/s00228-018-2524-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/11/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Although randomized controlled trials (RCTs) are the gold standard for the assessment of clinical outcomes, long-term extension trials (LTEs) and observational cohorts may help generate evidence. Our goal was to compare the discontinuation rates of abatacept, rituximab, and tocilizumab in rheumatoid arthritis (RA) reported in different study designs. METHODS A systematic review was conducted with searches in PubMed, Scopus, and the Cochrane Library, plus a manual search, for RCTs, LTEs, and observational cohorts reporting discontinuation rates by any of three causes (all-cause, inefficacy, adverse events). Meta-analyses with sensitivity analyses and meta-regressions were conducted. RESULTS Of the 111 studies included, 74 were RCTs (n = 55) or LTEs (n = 17) reporting data on abatacept (n = 33), rituximab (n = 10), and tocilizumab (n = 31) and 37 were observational cohort studies (abatacept = 11, rituximab = 8, tocilizumab = 18). The follow-up duration did not differ among the study designs. Discontinuation rates were similar among the drugs but varied among the study designs. Discontinuation rates were significantly higher in cohort studies than those in interventional studies for the three drugs. Sensitivity analyses could not identify patient characteristics associated with these differences. Meta-regression analyses demonstrated no correlation between study follow-up duration and discontinuation rates. CONCLUSIONS The discontinuation rates reported for non-anti-TNF drugs varied relative to the study design in which they were investigated. Regulatory agencies, price-setting entities, and evidence-gathering researchers should consider the effect of the real-life environment in their decisions and conclusions.
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Affiliation(s)
| | | | | | | | - Helena H Borba
- Department of Pharmacy, Universidade Federal do Paraná, Av. Pref. Lothário Meissner, 632, Curitiba, Paraná, Brazil
| | - Thais Piazza
- Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Fernando Fernandez-Llimos
- Research Institute for Medicines (iMed.ULisboa), Department of Social Pharmacy, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Roberto Pontarolo
- Department of Pharmacy, Universidade Federal do Paraná, Av. Pref. Lothário Meissner, 632, Curitiba, Paraná, Brazil
| | - Astrid Wiens
- Department of Pharmacy, Universidade Federal do Paraná, Av. Pref. Lothário Meissner, 632, Curitiba, Paraná, Brazil.
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14
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Vespasiani-Gentilucci U, Pedone C, Muley-Vilamu M, Antonelli-Incalzi R. The pharmacological treatment of chronic comorbidities in COPD: mind the gap! Pulm Pharmacol Ther 2018; 51:48-58. [PMID: 29966745 DOI: 10.1016/j.pupt.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is commonly associated with other chronic diseases, which poses several diagnostic and therapeutic problems. Indeed, important comorbidities frequently remain unrecognized and, then, untreated, whereas respiratory drugs may have non respiratory side effects, and selected non respiratory drugs may variably affect the respiratory function. OBJECTIVE to describe: how COPD affects the presentation and contributes to the diagnostic challenges of its most common comorbidities; how coexisting COPD impacts the therapeutic approach to selected comorbidities and viceversa. METHODS we distinguish comorbidities of COPD depending upon whether they are complications of COPD or share risk factors, mainly smoke, with it or, finally, aggravate COPD. We describe atypical presentations of and diagnostic clues to comorbidities and suggest screening procedures. Finally, the main therapeutic problems, as resulting from the risk of untoward effects of therapies of COPD and its comorbidity, with special attention to drug-drug interactions and possible overdosages, are described. RESULTS selected complications of COPD, such as osteoporosis, sarcopenia and dysphagia, are rarely recognized and treated, likely due to the poor awareness of them. Important comorbidities, such as coronary artery disease, chronic heart failure, obstructive sleep apnoea syndrome and chronic renal failure, also should be systematically searched for because of their commonly variant presentation. Disease-related symptoms should be distinguished from drug effects or drug-drug interaction effects. CONCLUSIONS a truly comprehensive view of the complex COPD patient, hopefully capitalizing on multidimensional geriatric assessment, is needed to dissect the many components of health status impairment and to provide the optimal care. Selected screening procedures are highly desirable to identify frequently missed comorbidities. Pharmacosurveillance is an essential part of the approach to COPD and its comorbidities.
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Affiliation(s)
| | - Claudio Pedone
- Internal Medicine and Geriatrics Area, University Campus Bio-Medico of Rome, Italy
| | - Moises Muley-Vilamu
- Internal Medicine and Geriatrics Area, University Campus Bio-Medico of Rome, Italy
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15
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Cogan J, Lalumière G, Vargas-Schaffer G, Deschamps A, Yegin Z. Low-dose intravenous ketamine for postcardiac surgery pain: Effect on opioid consumption and the incidence of chronic pain. Ann Card Anaesth 2018; 20:395-398. [PMID: 28994672 PMCID: PMC5661306 DOI: 10.4103/aca.aca_54_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Recent meta-analyses have concluded that low-dose intravenous ketamine infusions (LDKIs) during the postoperative period may help to decrease acute and chronic postoperative pain after major surgery. AIMS This study aims to evaluate the level of pain at least 3 months after surgery for patients treated with a postoperative LDKI versus patients who were not treated with a postoperative LDKI. METHODS Administrative and Ethics Board approval were obtained for this study. We performed a retrospective chart review for all patients receiving LDKI, and equal number of age-, sex-, and surgery-matched patients who did not receive LDKI. Low-dose ketamine was prepared using 100 mg of ketamine in 100 ml of normal saline and run between 50 and 200 mcg/kg/h. RESULTS We reviewed 115 patients with LDKI and 115 without LDKI. The average age was 63.1 years, 73% of the patients were men and sex was evenly distributed between LDKI and non-LDKI. The average duration of the ketamine infusions was 26.8 h with the average dose being 169.9 mg. At an average of 9 months after surgery, 42% of the ketamine group and 38% of the nonketamine group stated that they had had pain on discharge. Of these patients, 30% of the ketamine group and 26% of the nonketamine group still had pain at the time of the phone call. Women in both groups had more acute and chronic pain than men. CONCLUSION These results show that LDKI does not promote a decrease in long-term postoperative pain.
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Affiliation(s)
- Jennifer Cogan
- Department of Anesthesia, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Geneviève Lalumière
- Department of Anesthesia, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | | | - Alain Deschamps
- Department of Anesthesia, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Zeynep Yegin
- Department of Nursing, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
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16
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Kardos P, Mokros I, Sauer R, Vogelmeier CF. Health status in patients with COPD treated with roflumilast: two large noninterventional real-life studies: DINO and DACOTA. Int J Chron Obstruct Pulmon Dis 2018; 13:1455-1468. [PMID: 29765213 PMCID: PMC5939899 DOI: 10.2147/copd.s159827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose DINO and DACOTA were prospective, noninterventional studies assessing the health status and quality of life of patients with COPD newly treated with roflumilast 500 μg once-daily add-on therapy. Patients and methods Patients were evaluated over 6 months. Clinical COPD questionnaire (CCQ) and COPD assessment test (CAT) scores were recorded at baseline and after 3 and 6 months. In DACOTA, post-bronchodilator FEV1 was recorded at each time point. Results Of 5,462 and 3,645 patients recruited into DINO and DACOTA, respectively, 3,274 patients in DINO and 916 patients in DACOTA completed the 6-month visit. Almost all patients had severe or very severe airway obstruction; mean baseline CCQ total score was 3.9 in DINO and 3.7 in DACOTA. Overall, 33.8% of patients in DACOTA and 30.6% in DINO discontinued treatment prematurely. Significant and clinically relevant improvements in CCQ total scores were observed in both studies (mean change from baseline of 1.36 in DINO and 0.91 in DACOTA at Month 6 [all P<0.001]). Changes in CAT total score from baseline to Month 6 indicated that the average clinical impact of COPD was reduced from a severe (score: 21-30) to a moderate (score: 11-20) impairment. In DACOTA, mean change in post-bronchodilator FEV1 was 202 mL (P<0.001). Diarrhea, nausea, and weight decrease were the most frequently reported adverse drug reactions. Conclusion In real-life clinical practice, roflumilast treatment as an add-on therapy is associated with clinically relevant improvements in health status and quality of life.
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Affiliation(s)
- Peter Kardos
- Group Practice and Centre for Allergy, Respiratory, and Sleep Medicine, at Maingau Red Cross Hospital, Frankfurt am Main, Germany
| | - Ingo Mokros
- AstraZeneca GmbH, Unternehmensbereich Medizin, Wedel, Germany
| | - Rüdiger Sauer
- Group Practice with Respiratory, Allergy and Sleep Unite, Lung Center, Ulm, Germany
- Health Center Clinic Blaubeuren, Blaubeuren, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University Marburg, Marburg, Germany
- German Center for Lung Research (DZL), Giessen, Germany
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17
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Vierck CJ, Chapman CR. Prospective evaluation of chronic pain disorders and treatments. J Neurosci Methods 2018; 295:104-110. [PMID: 29198951 DOI: 10.1016/j.jneumeth.2017.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/23/2017] [Accepted: 11/29/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND The incidence of chronic pain is variable among individuals who have sustained traumatic or surgical injury. Also, treatments for pain rarely are effective consistently for a procedure or agent, and no therapies are considered effective for pain that is chronic. NEW METHOD Difficulties with standard methods for conducting clinical trials call attention to a need for protocols that provide a new understanding of the development of and control over chronic pain. Prospective single-subject research designs can document varieties of pain progression over time for individuals. Subsequent grouping of individuals with common characteristics directs a mechanism-based approach to therapy. RESULTS Tracking of individuals' pain and associated influences over time is consistent with clinical practice, noting and adapting to changes that occur. COMPARISON WITH EXISTING METHODS Grouping patients with diverse characteristics and variable effects of therapy is problematic. Conventional evaluation of pain assesses patients with similar injuries or surgery without characterizations of individuals who develop chronic pain or recover over time. Also, classical evaluation of therapies involves comparison of groups receiving treatment or a placebo without characterization of patients with successful and unsuccessful results. CONCLUSIONS Single-subject prospective studies can inform clinical trials according to individual differences that would be obscured by comparison of groups with unknown variation in characteristics that influence pain and therapeutic effectiveness.
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Affiliation(s)
- Charles J Vierck
- Department of Neuroscience, College of Medicine and McKnight Brain Institute, University of Florida, Gainesville, FL, 2610, United States.
| | - C Richard Chapman
- Department of Anesthesiology, School of Medicine, University of Utah, Salt Lake City, UT, 84108, United States
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18
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Albertson TE, Murin S, Sutter ME, Chenoweth JA. The Salford Lung Study: a pioneering comparative effectiveness approach to COPD and asthma in clinical trials. Pragmat Obs Res 2017; 8:175-181. [PMID: 29033625 PMCID: PMC5614786 DOI: 10.2147/por.s144157] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The Salford Lung Study (SLS) of patients with asthma and chronic obstructive pulmonary disease (COPD) is a practical, community-based, randomized, open-label pragmatic study on the efficacy and safety of the once-daily dry powder inhaler that combines the inhaled corticosteroid fluticasone furoate (FF) with the long-acting beta2 agonist vilanterol (VI). The asthma component of the SLS is not yet reported but the COPD component, done over a 12-month period, found a statistically significant 8.4% reduction in COPD exacerbations when compared to usual care. No differences in adverse events, including serious adverse events and pneumonia, were noted. The importance of real-world findings, such as those found in the SLS COPD trial with inhaled FF/VI, is discussed in comparison to classical randomized controlled trials (RCTs) with inhaled FF/VI in COPD patients. The real-world, community-based pragmatic RCT like the SLS provides additional generalizable data with direct clinical applicability and potential usefulness in the development of practice guidelines. The results from the SLS, along with those of large and small RCTs, are supportive of the use of once-daily FF/VI in COPD maintenance therapy.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento.,Department of Medicine, Veterans Administration Northern California Healthcare System, Mather.,Department of Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento.,Department of Medicine, Veterans Administration Northern California Healthcare System, Mather
| | - Mark E Sutter
- Department of Medicine, Veterans Administration Northern California Healthcare System, Mather.,Department of Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - James A Chenoweth
- Department of Medicine, Veterans Administration Northern California Healthcare System, Mather.,Department of Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
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19
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Agabiti N, Corbo GM. COPD and bronchodilators: should the heart pay the bill for the lung? Eur Respir J 2017; 49:49/5/1700370. [PMID: 28536252 DOI: 10.1183/13993003.00370-2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Nera Agabiti
- Dept of Epidemiology, Lazio Regional Health Service, Rome, Italy
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