Severe exacerbation and pneumonia in COPD patients treated with fixed combinations of inhaled corticosteroid and long-acting beta2 agonist

May a different kinetic mode explain the high efficacy/safety profile of inhaled budesonide?

The claimed functional basis for ICSs in asthma and COPD is airway selectivity, attained by inhaling a potent, lipophilic compound with long local dissolution/absorption time. The development has been empirically based, resulting in five widely used ICSs. Among them, budesonide (BUD) deviates by being less lipophilic, leading to a more rapid systemic uptake with plasma peaks with some systemic anti-inflammatory activity. By this, BUD fits less well into the current pharmacological dogma of optimal ICS profile. In this review we compared the physicochemical, pharmacological and clinical properties of BUD, fluticasone propionate (FP) and fluticasone furoate (FF), representing different levels of lipophilicity, airway and systemic kinetics, focusing on their long-acting β2-agonist (LABA) combinations, in line with current GINA and GOLD recommendations. We are aware of the differences between formoterol (FORM) and the not rapid acting LABAs such as e.g. salmeterol and vilanterol but our comparisons are based on currently available combination products. A beclomethasone dipropionate (BDP)/FORM combination is also commented upon. Based on clinical comparisons in asthma and COPD, we conclude that the BUD/formoterol (BUD/FORM) combination is as effective and safe as the FP and FF combinations, and is in some cases even better as it can be used as "maintenance plus reliever therapy" (MART) in asthma and as maintenance in COPD. This is difficult to explain by current views of required ICS's/LABAs pharmacokinetic profiles. We propose that BUD achieves its efficacy by a combination of airway and systemic activity. The airway activity is dominating. The systemic activity contributes by plasma peaks, which are high enough for supportive anti-inflammatory actions at the blood and bone marrow levels but not sufficiently long to trigger a similar level of systemic adverse effects. This may be due to BUD's capacity to exploit a systemic differentiation mechanism as programmed for cortisol's various actions. This differentiation prospect can be reached only for an ICS with short plasma half-life. Here we present an alternative mode for an ICS to reach combined efficacy and safety, based on a poorly investigated and exploited physiological mechanism. A preference of this mode is broader versatility, due to that its straighter dose-response should allow a better adaptation to disease fluctuations, and that its rapid activity enables use as "anti-inflammatory reliever".

Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD

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.

Real-World Evidence: Bridging Gaps in Evidence to Guide Payer Decisions

Randomized controlled trials (RCTs) are preferred by payers for health technology assessments and coverage decisions. However, the inclusion of a highly selective patient population and the rigorously controlled conditions in RCTs may not be reflective of real-world clinical practice. Real-world evidence (RWE) obtained from an analysis of real-world data (RWD) from observational studies can bridge gaps in evidence not addressed by RCTs and is thus valuable to public and private payers for decision-making. Through a broad literature search to obtain insights into payers' experience, we found that payers have concerns about real-world studies with respect to data quality, poor internal validity, potential bias, and lack of meaningful endpoints. However, they valued RWE to fill evidence gaps not addressed by RCTs, such as high-quality, real-world, long-term effectiveness and safety data; head-to-head drug comparisons; cost analyses for tiering formulary placement; medication use and adherence patterns; identification of relevant responder and non-responder patient subpopulations; and patient-reported outcomes (PROs). RWE can be used to assess clinically meaningful endpoints and gauge the impact of interventions on the quality of healthcare. Here, we review how payers use or can use RWD on the comparative effectiveness and safety of treatments, PROs, medication adherence and persistence, prescribing patterns, healthcare resource utilization, and patient characteristics and/or biomarkers associated with treatment response when making health technology assessments and payer coverage decisions across therapeutic areas.

Intraclass Difference in Pneumonia Risk with Fluticasone and Budesonide in COPD: A Systematic Review of Evidence from Direct-Comparison Studies

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.

Treatment with inhaled corticosteroids in chronic obstructive pulmonary disease

In chronic obstructive pulmonary disease (COPD), treatment with inhaled corticosteroids (ICSs) in combination with long acting beta-2-agonists (LABA) or LABA/long-acting muscarinic antagonists (LAMA) is used in order to reduce exacerbations. Treatment with ICS is, however, associated with side effects such as oropharyngeal candidiasis, skin thinning or easy bruising and pneumonia. The aim of this review was to investigate when to use ICS in COPD and to compare the effectiveness and safety of different ICSs. Studies comparing the effect of ICS/LABA and LABA/LAMA on exacerbations have shown divergent results, whereas most studies comparing ICS/LABA/LAMA (triple therapy) with LABA/LAMA have reported fewer exacerbations with triple therapy. Several investigations have shown that the number of eosinophils in blood predicts whether a patient will benefit from treatment with ICS. There is also data indicating that ICS has a small but significant positive effect on lung function decline and decrease mortality. There are four observational studies showing a better effect on exacerbations with budesonide/formoterol than fluticasone propionate/salmeterol and three observational studies showing less risk of pneumonia with budesonide than fluticasone propionate. Studies comparing the effect and safety of other ICSs such as fluticasone furoate and beclomethasone are too few to draw firm conclusions from. In conclusion, ICS together with LABA or LABA/LAMA reduces the risk of exacerbations in COPD. The indication of using ICS in COPD is stronger if the patient has increased blood eosinophils levels. There are data indicating that the choice of ICS matters, with studies showing a better effect-safety profile with budesonide compared to fluticasone propionate whereas it is not possible to make benefit-risk comparisons between the other licensed ICSs.

Asthma and treatment with inhaled corticosteroids: associations with hospitalisations with pneumonia

BACKGROUND

Pneumonia is an important cause of morbidity and mortality. COPD patients using inhaled corticosteroids (ICS) have an increased risk of pneumonia, but less is known about whether ICS treatment in asthma also increases the risk of pneumonia. The aim of this analysis was to examine risk factors for hospitalisations with pneumonia in a general population sample with special emphasis on asthma and the use of ICS in asthmatics.

METHODS

In 1999 to 2000, 7340 subjects aged 28 to 54 years from three Swedish centres completed a brief health questionnaire. This was linked to information on hospitalisations with pneumonia from 2000 to 2010 and treatment with ICS from 2005 to 2010 held within the Swedish National Patient Register and the Swedish Prescribed Drug Register.

RESULTS

Participants with asthma (n = 587) were more likely to be hospitalised with pneumonia than participants without asthma (Hazard Ratio (HR 3.35 (1.97-5.02)). Other risk factors for pneumonia were smoking (HR 1.93 (1.22-3.06)), BMI < 20 kg/m2 (HR 2.74 (1.41-5.36)) or BMI > 30 kg/m2 (HR 2.54 (1.39-4.67)). Asthmatics (n = 586) taking continuous treatment with fluticasone propionate were at an increased risk of being hospitalized with pneumonia (incidence risk ratio (IRR) 7.92 (2.32-27.0) compared to asthmatics that had not used fluticasone propionate, whereas no significant association was found with the use of budesonide (IRR 1.23 (0.36-4.20)).

CONCLUSION

Having asthma is associated with a three times higher risk of being hospitalised for pneumonia. This analysis also indicates that there are intraclass differences between ICS compounds with respect to pneumonia risk, with an increased risk of pneumonia related to fluticasone propionate.

The Impact of Sepsis on the Outcomes of COPD Patients: A Population-Based Cohort Study

This study aims to identify the impact of new-onset sepsis in patients with chronic obstructive pulmonary disease (COPD) including the effects on acute exacerbations, pneumonia and mortality. Using the National Health Insurance Research Database of Taiwan, all patients with COPD older than 40 years between 1988 and 2010 were recruited. After propensity score matching, each of the 8774 COPD patients with and without sepsis were identified to have similar characteristics. The primary outcome was severe exacerbations of COPD, with a severe exacerbation being defined as a patient requiring hospital admission or an emergency department visit due to COPD. The secondary outcomes were pneumonia, serious pneumonia, and all-cause mortality. The post-index overall cumulative incidence rates of total acute exacerbations were 11.2/person-years in the sepsis group and 6.2/person-years in the non-sepsis group (adjusted hazard ratio (HR) = 1.38, 95% confidence interval (CI), 1.38⁻1.40). The sepsis group also had higher risks of severe exacerbations (adjusted HR = 2.05, 95% CI, 2.02⁻2.08), severe exacerbations requiring hospitalization (adjusted HR = 2.30, 95% CI, 2.24⁻2.36), and severe exacerbations leading to an emergency room visit (adjusted HR = 1.91, 95% CI, 1.87⁻1.94). Regarding the effect on secondary outcomes, the sepsis group had higher risks of mortality (incidence rate: 23.7/person-years vs. 11.34/person-years, adjusted HR = 2.27, 95% CI, 2.14⁻2.41), pneumonia (incidence rate: 26.41 per person-days vs. 10.34 per person-days, adjusted HR = 2.70, 95% CI, 2.5⁻2.91), and serious pneumonia (incidence rate: 5.84 per person-days vs. 1.98 per person-days, adjusted HR = 2.89, 95% CI, 2.5⁻3.33) compared with the non-sepsis group. Sepsis survivors among patients with COPD had a higher risk of severe exacerbations, pneumonia, serious pneumonia, and mortality compared to patients with COPD without sepsis.

Comparison of fluticasone propionate and budesonide on COPD macrophage and neutrophil function

Background

Inhaled corticosteroid use is associated with increased rates of pneumonia in COPD patients. The underlying mechanism is unknown, although recent data suggest that pneumonia is more frequent in patients treated with fluticasone propionate (FP) than budesonide. Macrophages and neutrophils from COPD patients are deficient in clearing bacteria, and this might explain increased bacterial colonization in COPD. Inhaled corticosteroid may further suppress this response; therefore, we examined the effect of FP and budesonide on phagocytosis of common respiratory pathogens by monocyte-derived macrophages (MDMs) and neutrophils.

Methods

MDMs from COPD patients (n=20–24) were preincubated with FP or budesonide for 1 or 18 hours, after which phagocytosis of fluorescently labeled inert beads or heat-killed Haemophilus influenzae/Streptococcus pneumoniae were measured fluorimetrically after 1 or 4 hours. Additionally, CXCL8, IL6, and TNFα concentrations in supernatants by ELISA, MDM-scavenger-receptor expression by flow cytometry, and MDM ability to kill bacteria were measured. Neutrophils from COPD patients (n=8) were preincubated with corticosteroids for 1 hour and bacteria phagocytosis measured by flow cytometry.

Results

After 1 hour’s preincubation, neither corticosteroid altered MDM phagocytosis of beads or H. influenzae; however, budesonide (10⁻⁷ M) increased S. pneumoniae phagocytosis by 23% (P<0.05). After 18 hours’ preincubation, neither corticosteroid altered MDM phagocytosis of any prey, although H. influenzae phagocytosis by budesonide was significantly greater compared to FP at 10⁻⁶ and 10⁻⁵ M (P<0.05). The 1-hour preincubation with either corticosteroid inhibited bacteria-induced CXCL8 release (at 10⁻⁷ and 10⁻⁵ M, P<0.05); however, this effect was lost at 18-hour preincubation. There was no change in receptor expression, bacterial killing, or neutrophil phagocytosis by either corticosteroid.

Conclusion

These data suggest that dissolved FP and budesonide do not have an overall effect on MDM or neutrophil phagocytosis of bacteria.

Identifying the associated risks of pneumonia in COPD patients: ARCTIC an observational study

Background

Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). Other factors such as severity of airflow limitation and concurrent asthma may further raise the possibility of developing pneumonia. This study assessed the risk of pneumonia associated with ICS in patients with COPD.

Methods

Electronic Medical Record data linked to National Health Registries were collected from COPD patients and matched reference controls in 52 Swedish primary care centers (2000–2014). Levels of ICS treatment (high, low, no ICS) and associated comorbidities were assessed. Patients were categorized by airflow limitation severity.

Results

A total of 6623 patients with COPD and 48,566 controls were analyzed. Patients with COPD had a more than 4-fold increase in pneumonia versus reference controls (hazard ratio [HR] 4.76, 95% confidence interval [CI]: 4.48–5.06). ICS use increased the risk of pneumonia by 20–30% in patients with COPD with forced expiratory volume in 1 s ≥ 50% versus patients not using ICS. Asthma was an independent risk factor for pneumonia in the COPD population. Multivariate analysis identified independent predictors of pneumonia in the overall population. The highest risk of pneumonia was associated with high dose ICS (HR 1.41, 95% CI: 1.23–1.62).

Conclusions

Patients with COPD have a greater risk of pneumonia versus reference controls; ICS use and concurrent asthma increased the risk of pneumonia further.

Inhaled corticosteroids for chronic obstructive pulmonary disease: what is their role in therapy?

Inhaled corticosteroids (ICSs) are a mainstay of COPD treatment for patients with a history of exacerbations. Initial studies evaluating their use as monotherapy failed to show an effect on rate of pulmonary function decline in COPD, despite improvements in symptoms and reductions in exacerbations. Subsequently, ICS use in combination with long-acting β2-agonists (LABAs) was shown to provide improved reductions in exacerbations, lung function, and health status. ICS-LABA combination therapy is currently recommended for patients with a history of exacerbations despite treatment with long-acting bronchodilators alone. The presence of eosinophilic bronchial inflammation, detected by high blood eosinophil levels or a history of asthma or asthma-COPD overlap, may define a population of patients in whom ICSs may be of particular benefit. Prospective clinical studies to determine an appropriate threshold of eosinophil levels for predicting the beneficial effects of ICSs are needed. Further study is also required in COPD patients who continue to smoke to assess the impact of cell- and tissue-specific changes on ICS responsiveness. The safety profile of ICSs in COPD patients is confounded by comorbidities, age, and prior use of systemic corticosteroids. The risk of pneumonia in patients with COPD is increased, particularly with more advanced age and worse disease severity. ICS-containing therapy also has been shown to increase pneumonia risk; however, differences in study design and the definition of pneumonia events have led to substantial variability in risk estimates, and some data indicate that pneumonia risk may differ by the specific ICS used. In summary, treatment with ICSs has a role in dual and triple therapy for COPD to reduce exacerbations and improve symptoms. Careful assessment of COPD phenotypes related to risk factors, triggers, and comorbidities may assist in individualizing treatment while maximizing the benefit-to-risk ratio of ICS-containing COPD treatment.

Effects of fluticasone propionate and budesonide on the expression of immune defense genes in bronchial epithelial cells

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.

Comparative effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on the risk of pneumonia and severe exacerbations in patients with COPD

Objectives

This study aimed to compare the effects of angiotensin-converting-enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) on the risk of pneumonia and severe exacerbations in patients with COPD.

Patients and methods

All patients with COPD who used ACEis and ARBs for >90 days between 2000 and 2005 were recruited. Pairwise matching (1:1) of the ACEi and ARB groups resulted in two similar subgroups, with 6,226 patients in each. The primary outcomes were pneumonia and COPD exacerbations, and the secondary outcome was death.

Results

During the follow-up period, the incidence of pneumonia was 7.20 per 100 person-years in the ACEi group and 5.89 per 100 person-years in the ARB group. The ACEi group had a higher risk of pneumonia (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.15–1.29) than the ARB group. The incidence of severe exacerbations was 0.65 per person-year for the patients receiving ACEis and 0.52 per person-year for those receiving ARBs. The patients receiving ACEis had a higher risk of severe exacerbations (aHR, 1.19; 95% CI, 1.16–1.21) than those receiving ARBs. Similar trends were noted in terms of severe exacerbations requiring hospitalization (aHR, 1.24; 95% CI, 1.21–1.28) or emergency department visits (aHR, 1.16; 95% CI, 1.13–1.18), pneumonia requiring mechanical ventilation (aHR, 1.35; 95% CI, 1.24–1.47), and mortality (aHR, 1.33; 95% CI, 1.26–1.42).

Conclusion

ARBs were associated with lower rates of pneumonia, severe pneumonia, and mortality than ACEis in patients with COPD.

Trends in health care resource utilization and pharmacological management of COPD in Taiwan from 2004 to 2010

RATIONALE

COPD has attracted widespread attention worldwide. The prevalence of COPD in Taiwan has been reported, but little is known about trends in health care resource utilization and pharmacologic management in COPD treatment.

OBJECTIVE

The objective of this article was to study trends in health care resource utilization, pharmacologic management, and medical costs of COPD treatment in Taiwan.

MATERIALS AND METHODS

Reimbursement claims in the Taiwan National Health Insurance System from 2004 to 2010 were collected. The disease burden of COPD, including health care resource utilization and medical costs, was evaluated.

RESULTS

The pharmacy cost of COPD increased from 2004 to 2010 due to the increased utilization of long-acting muscarinic antagonist (LAMA) and fixed-dose combination of long-acting β2-agonist and inhaled corticosteroid (LABA/ICS), whereas the cost of all other COPD-related medications decreased. The average outpatient department (OPD) cost per patient increased 29.3% from 1,070 USD in 2004 to 1,383 USD in 2010. The highest average total medical cost per patient was 3,434 USD in 2005, and it decreased 12.4% to 3,008 USD in 2010. There was no significant difference in the average number of OPD visits and emergency department visits per patient. The highest average number of hospital admissions was 0.81 in 2005, and it decreased to 0.65 in 2010. The average number of intensive care unit (ICU) admissions decreased from 0.52 in 2005 to 0.31 in 2010.

CONCLUSION

From 2004 to 2010, the average total medical cost per patient of COPD was slightly decreased because of the decreased average number of hospital admissions and ICU admissions. The costs of both LAMA and LABA/ICS increased, while the cost for all other COPD-related medications decreased. These findings suggest that the increased utilization of LAMA and LABA/ICS may have contributed to the decreased average number of hospital admissions and ICU admissions in COPD patients from 2004 to 2010.