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Wang MT, Lin CW. Environmentally friendly inhaler regimens for COPD. BMJ 2024; 387:q2825. [PMID: 39797804 DOI: 10.1136/bmj.q2825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2025]
Affiliation(s)
- Meng-Ting Wang
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Wongsurakiat P, Rattanawongpaibul A, Limsukon A, Chiewchalermsri C, Wiwatcharagoses K, Kornthatchapong K, Saiphoklang N, Sanguanwit P, Domthong P, Kawamatawong T, Sewatanon T, Reechaipichitkul W, Maneechotesuwan K. Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand. J Asthma 2024; 61:1136-1151. [PMID: 38527278 DOI: 10.1080/02770903.2024.2334897] [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: 01/15/2024] [Revised: 03/17/2024] [Accepted: 03/20/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults. DATA SOURCES We conducted a search on PubMed for nebulized budesonide treatment. SELECTED STUDIES Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies. RESULTS Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings. CONCLUSION Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.
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Affiliation(s)
- Phunsup Wongsurakiat
- Division of Respiratory Diseases and Tuberculosis, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Atikun Limsukon
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chirawat Chiewchalermsri
- Department of Internal Medicine, Panyananthaphikkhu Chonprathan Medical Center Srinakharinwirot University, Nonthaburi, Thailand
| | - Kittiyaporn Wiwatcharagoses
- Department of Emergency Medicine, Faculty of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | | | - Narongkorn Saiphoklang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Pitsucha Sanguanwit
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornanan Domthong
- Division of Pulmonary and Critical Care Division, Department of Internal Medicine, Khon Kaen Hospital, Khon Kaen, Thailand
| | - Theerasuk Kawamatawong
- Associate Professor of Medicine, General Secretariate, Thai Asthma Council (TAC), Bangkok, Thailand
| | - Tirachat Sewatanon
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Wipa Reechaipichitkul
- Division of Pulmonary and Critical Care Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kittipong Maneechotesuwan
- Division of Respiratory Diseases and Tuberculosis, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Cazzola M, Ora J, Maniscalco M, Rogliani P. A clinician's guide to single vs multiple inhaler therapy for COPD. Expert Rev Respir Med 2024; 18:457-468. [PMID: 39044348 DOI: 10.1080/17476348.2024.2384702] [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: 05/14/2024] [Accepted: 07/22/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION In the management of chronic obstructive pulmonary disease (COPD), inhalation therapy plays a pivotal role. However, clinicians often face the dilemma of choosing between single and multiple inhaler therapies for their patients. This choice is critical because it can affect treatment efficacy, patient adherence, and overall disease management. AREAS COVERED This article examines the advantages and factors to be taken into consideration when selecting between single and multiple inhaler therapies for COPD. EXPERT OPINION Both single and multiple inhaler therapies must be considered in COPD management. While single inhaler therapy offers simplicity and convenience, multiple inhaler therapy provides greater flexibility and customization. Clinicians must carefully evaluate individual patient needs and preferences to determine the most appropriate inhaler therapy regimen. Through personalized treatment approaches and shared decision-making, clinicians can optimize COPD management and improve patient well-being. Nevertheless, further research is required to compare the effectiveness of single versus multiple inhaler strategies through rigorous clinical trials, free from industry bias, to determine the optimal inhaler strategy. Smart inhaler technology appears to have the potential to enhance adherence and personalized management, but the relative merits of smart inhalers in single inhaler regimens versus multiple inhaler regimens remain to be determined.
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Affiliation(s)
- Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital "Fondazione Policlinico Tor Vergata", Rome, Italy
| | - Mauro Maniscalco
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, Telese Terme, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Respiratory Medicine, University Hospital "Fondazione Policlinico Tor Vergata", Rome, Italy
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Su VYF, Ding TL, Chang YL, Chou YC, Hwang HE, Chou CY, Hsu CC. Comparative effectiveness and safety of inhaled corticosteroid plus long-acting β 2-agonist fixed-dose combinations vs. long-acting muscarinic antagonist in bronchiectasis. Expert Rev Clin Pharmacol 2024; 17:157-164. [PMID: 38224017 DOI: 10.1080/17512433.2024.2306218] [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: 09/23/2023] [Accepted: 01/12/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND This study aimed to evaluate the effectiveness and safety of fixed-dose combination (FDC) inhaled corticosteroids/long-acting β2-agonists (ICS/LABA) in bronchiectasis. RESEARCH DESIGN AND METHODS A retrospective cohort study analyzed electronic medical records of bronchiectasis patients initiating ICS/LABA FDC or LAMA between 2007 and 2021. All bronchiectasis diagnoses were made by radiologists using high-resolution computed tomography. RESULTS Of the 1,736 patients, 1,281 took ICS/LABA FDC and 455 LAMA. Among the 694 propensity score matched patients, ICS/LABA FDC had comparable outcomes to LAMA, with HRs of 1.22 (95% CI 0.81-1.83) for hospitalized respiratory infection, 1.06 (95% CI 0.84-1.33) for acute exacerbation, and 1.06 (95% CI 0.66-1.02) for all-cause hospitalization. Beclomethasone/formoterol (BEC/FOR) or budesonide/formoterol (BUD/FOR) led to a lower risk of acute exacerbation compared to fluticasone/salmeterol (FLU/SAL) (BEC/FOR HR 0.59, 95% CI 0.43-0.81; BUD/FOR HR 0.68, 95% CI 0.50-0.93). BEC/FOR resulted in lower risks of hospitalized respiratory infection (HR 0.48, 95% 0.26-0.86) and all-cause hospitalization (HR 0.55, 95% 0.37-0.80) compared to FLU/SAL. CONCLUSION Our findings provide important evidence on the effectiveness and safety of ICS/LABA FDC compared with LAMA for bronchiectasis. BEC/FOR and BUD/FOR were associated with better outcomes than FLU/SAL.
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Affiliation(s)
- Vincent Yi-Fong Su
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Internal Medicine, Taipei City Hospital, Taipei City Government, Taipei, Taiwan
- Department of Exercise and Health Sciences, College of Kinesiology, University of Taipei, Taipei, Taiwan
| | - Ting-Lin Ding
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yueh-Ching Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsuen-En Hwang
- Department of Internal Medicine, Taipei City Hospital, Taipei City Government, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chian-Ying Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Lee EG, Kim Y, Hwang YI, Yoo KH, Lee SE, Jung KY, Lee D, Park YB, Rhee CK. Comparison of pneumonia incidence between long-acting muscarinic antagonist and inhaled corticosteroid plus long-acting beta agonist in patients with COPD. Sci Rep 2023; 13:8183. [PMID: 37210420 DOI: 10.1038/s41598-023-35223-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/15/2023] [Indexed: 05/22/2023] Open
Abstract
Few studies have directly compared the incidence of pneumonia in patients on common chronic obstructive pulmonary disease (COPD) treatments such as long-acting muscarinic antagonists (LAMA) with those on inhaled corticosteroids and long-acting β2-agonist (ICS/LABA). Moreover, risk factors for pneumonia in COPD are still unclear. We aimed to compare the incidence of pneumonia in COPD patients on LAMA and those on ICS/LABA and explored the risk factors associated with pneumonia. This nationwide cohort study used Korean National Health Insurance claim data from January 2002 to April 2016. Patients who received COPD medication, either LAMA or ICS/LABA, with the COPD diagnostic code, were selected. We enrolled patients with good compliance (medication possession ratio ≥ 80%). The primary outcome was pneumonia in COPD patients initiating LAMA or ICS/LABA. We investigated the risk factors associated with pneumonia, including the sub-types of ICS treatments. After propensity score matching, the incidence rate per 1000 person-years of pneumonia was 93.96 for LAMA (n = 1003) and 136.42 for ICS/LABA (n = 1003) patients (p < 0.001). The adjusted hazard ratio (HR) for pneumonia in patients on fluticasone/LABA was 1.496 (95% confidence interval [CI] 1.204-1.859) compared with LAMA (p < 0.001). In multivariable analysis, a history of pneumonia was a risk factor associated with pneumonia (HR 2.123; 95% CI 1.580-2.852; p < 0.001). The incidence of pneumonia was higher in COPD patients on ICS/LABA compared with those on LAMA. It is recommended that ICS use be avoided in COPD patients with high pneumonia risk.
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Affiliation(s)
- Eung Gu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Youlim Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University Hospital, School of Medicine, Konkuk University, Seoul, South Korea
| | - Yong Il Hwang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang-Si, Gyeonggi-Do, South Korea
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University Hospital, School of Medicine, Konkuk University, Seoul, South Korea
| | - So Eun Lee
- Medical Affairs, Boehringer-Ingelheim, Seoul, South Korea
| | | | - Doik Lee
- Real-World Solutions, IQVIA, Seoul, South Korea
| | - Yong Bum Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-Gu, Seoul, 06591, South Korea.
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Heraganahally S, Howarth TP, Issac S, Lloyd A, Ravichandran SJ, Abeyaratne A, Patel B. Exploring the appropriateness of prescribing practice of inhaled pharmacotherapy among Aboriginal Australians in the Top End Northern Territory of Australia: a retrospective cohort study. BMJ Open Respir Res 2023; 10:10/1/e001508. [PMID: 36878611 PMCID: PMC9990608 DOI: 10.1136/bmjresp-2022-001508] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Aboriginal Australians are reported to have a high burden of chronic airway diseases. However, prescribing patterns and related outcomes of airway directed inhaled pharmacotherapy, (short-acting beta agonists (SABA), short-acting muscarinic antagonists (SAMA), long-acting β-agonists (LABA), long-acting muscarinic antagonists (LAMA) and inhaled corticosteroids (ICS)) among Aboriginal Australian patients with chronic airway disease have been sparsely reported in the past. METHODS A retrospective cohort study was conducted, using clinical, spirometry data, chest radiology, primary healthcare (PHC) presentations and hospital admission rates among Aboriginal patients identified to have been prescribed inhaled pharmacotherapy in remote and rural communities referred to the respiratory specialist service in the Top End, Northern Territory of Australia. RESULTS Of the 372 identified active patients, 346 (93%) had inhaled pharmacotherapy prescribed (64% female, median age 57.7 years). ICS was the most common prescription (72% of the total cohort) and was recorded to be prescribed in 76% of patients with bronchiectasis, and 80% of patients with asthma or chronic obstructive pulmonary disease (COPD). Fifty-eight percent of patients had a respiratory hospital admission and 57% had a recorded PHC presentation for a respiratory issue during the study period, with a higher rate of hospital admissions among patients prescribed ICS compared with those on SAMA/SABA or LAMA/LABA without ICS (median rate (per person per year) 0.42 vs 0.21 and 0.21 (p=0.004). Regression models demonstrated that presence of COPD or bronchiectasis alongside ICS was associated with significantly increased hospitalisation rates (1.01 admissions/person/year (95% CI 0.15 to 1.87) and 0.71 admissions/person/year (95% CI 0.23 to 1.18) against patients without COPD/bronchiectasis, respectively). CONCLUSIONS This study demonstrates that among Aboriginal patients with chronic airway diseases, ICS is the most common inhaled pharmacotherapy prescribed. Although LAMA/LABA and concurrent ICS use may be appropriate among patients with asthma and COPD, the use of ICS may have detrimental effects among those with underlying bronchiectasis either in isolation or concurrent COPD and bronchiectasis, potentially leading to higher hospital admission rates.
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Affiliation(s)
- Subash Heraganahally
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia .,Darwin Respiratory and Sleep Health, Darwin Private Hospital, Darwin, Northern Territory, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Timothy P Howarth
- Darwin Respiratory and Sleep Health, Darwin Private Hospital, Darwin, Northern Territory, Australia.,College of Health and Human Sciences, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
| | - Siji Issac
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Angus Lloyd
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | | | - Asanga Abeyaratne
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Bhavini Patel
- Medicines Management and Clinical Innovation and Research, Department of Health, Darwin, Northern Territory, Australia
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Yu I, Park S, Hong SH, Chang MS, Lee SJ, Yong SJ, Lee WY, Kim SH, Lee JH. Risk of Tuberculosis Caused by Fluticasone Propionate versus Budesonide in Chronic Obstructive Pulmonary Disease: A Nationwide Population-Based Study. J Pers Med 2022; 12:jpm12071189. [PMID: 35887686 PMCID: PMC9321025 DOI: 10.3390/jpm12071189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/09/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022] Open
Abstract
Background: In chronic obstructive pulmonary disease (COPD), inhaled corticosteroids (ICSs) are recommended for use by patients with frequent exacerbations and blood eosinophilia. However, ICSs are often inappropriately prescribed and overused. COPD studies have reported an increased risk of tuberculosis among ICS users. This study aimed to compare the risk of tuberculosis according to the different ICS components. Methods: This study was conducted using a nationwide, population-based cohort. Patients newly diagnosed with COPD between 2005 and 2018, and treated with either fluticasone propionate or budesonide, were selected. The patients were followed up until the development of tuberculosis. Results: After propensity score matching, 16,514 fluticasone propionate and 16,514 budesonide users were identified. The incidence rate of tuberculosis per 100,000 person-years was 274.73 for fluticasone propionate and 214.18 for budesonide. The hazard ratio of tuberculosis in fluticasone propionate compared with budesonide was 1.28 (95% confidence interval 1.05–1.60). The risk of tuberculosis for fluticasone propionate increased with higher ICS cumulative doses: 1.01 (0.69–1.48), 1.16 (0.74–1.81), 1.25 (0.79–1.97), and 1.82 (1.27–2.62) from the lowest to highest quartiles, respectively. Conclusion: Fluticasone propionate is associated with a higher risk of tuberculosis than budesonide. ICS components can differently affect the risk of tuberculosis in patients with COPD.
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Affiliation(s)
- Iseul Yu
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Sunmin Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Se Hwa Hong
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Min-Seok Chang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Seok Jeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Suk Joong Yong
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Sang-Ha Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
| | - Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (I.Y.); (S.P.); (M.-S.C.); (S.J.L.); (S.J.Y.); (W.-Y.L.); (S.-H.K.)
- Correspondence:
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Cazzola M, Ora J, Calzetta L, Rogliani P, Matera MG. Advances in inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease: what is their value today? Expert Opin Pharmacother 2022; 23:917-927. [PMID: 35575510 DOI: 10.1080/14656566.2022.2076592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION As of today, there is still a need to determine which COPD patients may benefit from ICS therapy, whether ICSs are useful in COPD patients without chronic bronchitis, and whether long-acting bronchodilators can reduce the risk of exacerbations in frequent exacerbators even if ICSs are not used, and whether combination therapy including ICSs is helpful in infrequent exacerbators to optimise the use of ICSs in COPD. Nevertheless, in recent years, a fair amount of evidence has been produced that, at least in part, can help define the role of ICSs in COPD better. AREAS COVERED Herein, the authors provide an overview of current use of ICS in COPD and discuss their value to the current treatment armamentarium. The article includes discussion of which patients will benefit best from the use of ICSs, their potential uses and adverse effects. EXPERT OPINION There is growing agreement on why, in whom, and when ICS therapy can be used in COPD, although the consensus is still lacking because of the heterogeneity of COPD. The use of blood eosinophil counts (BECs) is only helpful in T2 inflammation, while there is a lack of biomarkers indicating the presence of T1 and T17 immunity, which is poorly responsive to ICS. Identifying ICS-sensitive endotypes using specific biomarkers that have yet to be identified and validated is likely to demonstrate that ICSs can influence the natural course of COPD in at least a subset of patients.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Josuel Ora
- Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Inhaled Corticosteroids Selectively Alter the Microbiome and Host Transcriptome in the Small Airways of Patients with Chronic Obstructive Pulmonary Disease. Biomedicines 2022; 10:biomedicines10051110. [PMID: 35625847 PMCID: PMC9138653 DOI: 10.3390/biomedicines10051110] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Patients with chronic obstructive pulmonary disease (COPD) are commonly treated with inhaled corticosteroid/long-acting ß2-agonist combination therapy. While previous studies have investigated the host–microbiome interactions in COPD, the effects of specific steroid formulations on this complex cross-talk remain obscure. Methods: We collected and evaluated data from the Study to Investigate the Differential Effects of Inhaled Symbicort and Advair on Lung Microbiota (DISARM), a randomized controlled trial. Bronchoscopy was performed on COPD patients before and after treatment with salmeterol/fluticasone, formoterol/budesonide or formoterol-only. Bronchial brush samples were processed for microbial 16S rRNA gene sequencing and host mRNA sequencing. Longitudinal changes in the microbiome at a community, phylum and genus level were correlated with changes in host gene expression using a Spearman’s rank correlation test. Findings: In COPD patients treated with salmeterol/fluticasone, the expression levels of 676 host genes were significantly correlated to changes in the alpha diversity of the small airways. At a genus level, the expression levels of 122 host genes were significantly related to changes in the relative abundance of Haemophilus. Gene enrichment analyses revealed the enrichment of pathways and biological processes related to innate and adaptive immunity and inflammation. None of these changes were evident in patients treated with formoterol/budesonide or formoterol alone. Interpretation: Changes in the microbiome following salmeterol/fluticasone treatment are related to alterations in the host transcriptome in the small airways of patients with COPD. These data may provide insights into why some COPD patients treated with inhaled corticosteroids may be at an increased risk for airway infection, including pneumonia. Funding: The Canadian Institute of Health Research, the British Columbia Lung Association, and an investigator-initiated grant from AstraZeneca.
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Zhao Y, Zhang R, Zhong Y, Wang J, Weng Z, Luo H, Chen C. Statistical Analysis and Machine Learning Prediction of Disease Outcomes for COVID-19 and Pneumonia Patients. Front Cell Infect Microbiol 2022; 12:838749. [PMID: 35521216 PMCID: PMC9063041 DOI: 10.3389/fcimb.2022.838749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/07/2022] [Indexed: 01/22/2023] Open
Abstract
The Coronavirus Disease 2019 (COVID-19) has spread all over the world and impacted many people’s lives. The characteristics of COVID-19 and other types of pneumonia have both similarities and differences, which confused doctors initially to separate and understand them. Here we presented a retrospective analysis for both COVID-19 and other types of pneumonia by combining the COVID-19 clinical data, eICU and MIMIC-III databases. Machine learning models, including logistic regression, random forest, XGBoost and deep learning neural networks, were developed to predict the severity of COVID-19 infections as well as the mortality of pneumonia patients in intensive care units (ICU). Statistical analysis and feature interpretation, including the analysis of two-level attention mechanisms on both temporal and non-temporal features, were utilized to understand the associations between different clinical variables and disease outcomes. For the COVID-19 data, the XGBoost model obtained the best performance on the test set (AUROC = 1.000 and AUPRC = 0.833). On the MIMIC-III and eICU pneumonia datasets, our deep learning model (Bi-LSTM_Attn) was able to identify clinical variables associated with death of pneumonia patients (AUROC = 0.924 and AUPRC = 0.802 for 24-hour observation window and 12-hour prediction window). The results highlighted clinical indicators, such as the lymphocyte counts, that may help the doctors to predict the disease progression and outcomes for both COVID-19 and other types of pneumonia.
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Affiliation(s)
- Yu Zhao
- College of Computer and Data Science, Fuzhou University, Fuzhou, China
- Centre for Big Data Research in Burns and Trauma, Fuzhou University, Fuzhou, China
| | - Rusen Zhang
- Department of Cardiovascular Medicine, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Yi Zhong
- College of Computer and Data Science, Fuzhou University, Fuzhou, China
- Centre for Big Data Research in Burns and Trauma, Fuzhou University, Fuzhou, China
| | - Jingjing Wang
- Department of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, China
| | - Zuquan Weng
- Centre for Big Data Research in Burns and Trauma, Fuzhou University, Fuzhou, China
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
- *Correspondence: Zuquan Weng, ; Heng Luo, ; Cunrong Chen,
| | - Heng Luo
- College of Computer and Data Science, Fuzhou University, Fuzhou, China
- Centre for Big Data Research in Burns and Trauma, Fuzhou University, Fuzhou, China
- MetaNovas Biotech Inc., Foster City, CA, United States
- *Correspondence: Zuquan Weng, ; Heng Luo, ; Cunrong Chen,
| | - Cunrong Chen
- Department of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, China
- *Correspondence: Zuquan Weng, ; Heng Luo, ; Cunrong Chen,
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11
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Lai CC, Chen CH, Chen KH, Wang CY, Huang TM, Wang YH, Wang HC. The Impact of 52-Week Single Inhaler Device Triple Therapy versus Dual Therapy on the Mortality of COPD Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Life (Basel) 2022; 12:life12020173. [PMID: 35207460 PMCID: PMC8877713 DOI: 10.3390/life12020173] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/28/2022] Open
Abstract
There are more single inhaler device triple therapy available for COPD patients now. However, the effect of long-term triple therapy fixed dose combination (FDC) on mortality remains unclear. This study aimed to evaluate the impact of one-year single inhaler device triple therapy, including long-acting β2-agonists (LABAs), long-acting muscarinic receptor antagonists (LAMAs), and inhaled corticosteroids (ICSs), with dual therapies, comprised of either LABA/LAMA or ICS/LABA, on the mortality of patients with COPD. We searched the PubMed, Cochrane library, Web of Science, Embase databases, and clinical trial registry of clinicaltrials.gov and WHO ICTRP. Randomized controlled trials (RCTs) compared single inhaler device triple and dual therapies for 52 weeks were selected for the meta-analysis. The primary endpoint was all-cause mortality. A total of 6 RCTs were selected for the meta-analysis, including 10,274 patients who received single inhaler device triple therapy (ICS/LABA/LAMA FDC) and 12,395 patients who received ICS/LABA or LABA/LAMA dual therapy. Risk of death was significantly lower in the ICS/LABA/LAMA FDC group compared to the LABA/LAMA group (RR = 0.69, 95% CI = 0.53–0.90, p = 0.007). There was no significant difference in mortality between the ICS/LABA/LAMA FDC and ICS/LABA therapy groups (RR = 0.94, 95% CI = 0.72–1.24, p = 0.66). In addition, patients receiving ICS/LABA/LAMA FDC therapy had less moderate or severe exacerbations compared with the dual therapy groups (RR = 0.76, 95% CI = 0.73–0.80, p < 0.001 for LABA/LAMA; RR = 0.84, 95% CI = 0.78–0.90, p < 0.001 for ICS/LABA). By contrast, the risk of pneumonia in the ICS/LABA/LAMA FDC group was higher than in the LABA/LAMA group (RR = 1.43, 95% CI = 1.21–1.68, p < 0.001). In conclusion, ICS/LABA/LAMA FDC therapy could help improve the clinical outcomes of patients with COPD. However, triple therapy could increase the risk of pneumonia in comparison with LABA/LAMA dual therapy.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan 710, Taiwan;
| | - Chao-Hsien Chen
- Division of Pulmonary, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan;
- Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan
| | - Kuang-Hung Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (K.-H.C.); (H.-C.W.)
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 231, Taiwan
- Correspondence: e-mail (C.-Y.W.); (T.-M.H.); (Y.-H.W.)
| | - Tsan-Ming Huang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 231, Taiwan
- Correspondence: e-mail (C.-Y.W.); (T.-M.H.); (Y.-H.W.)
| | - Ya-Hui Wang
- Medical Research Center, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 231, Taiwan
- Correspondence: e-mail (C.-Y.W.); (T.-M.H.); (Y.-H.W.)
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (K.-H.C.); (H.-C.W.)
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12
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Lee SC, Son KJ, Han CH, Jung JY, Park SC. Association between Inhaled Corticosteroid Use and SARS-CoV-2 Infection: A Nationwide Population-Based Study in South Korea. Tuberc Respir Dis (Seoul) 2022; 85:80-88. [PMID: 34844402 PMCID: PMC8743634 DOI: 10.4046/trd.2021.0102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/23/2021] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although it is known that inhaled corticosteroid (ICS) use may increase the risk of respiratory infection, its influence on the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains unknown. Thus, the aim of this study was to investigate the association between ICS use and the positivity of SARS-CoV-2 infection among patients with chronic respiratory diseases. METHODS Nationwide data of 44,968 individuals with chronic respiratory diseases tested for SARS-CoV-2 until May 15, 2021 were obtained from the Ministry of Health and Welfare and Health Insurance Review and Assessment Service in Korea. The positivity of SARS-CoV-2 infection was retrospectively analysed according to the prescription, type, and dose of ICS taken one year before SARS-CoV-2 test. RESULTS Among 44,968 individuals tested, 931 (2.1%) were positive for SARS-CoV-2. A total of 7,019 patients (15.6%) were prescribed ICS one year prior to being tested for SARS-CoV-2. Low, medium, and high doses of ICS were prescribed in 7.5%, 1.6%, and 6.5% of total cases, respectively. Among types of ICS, budesonide, fluticasone, beclomethasone, and ciclesonide were prescribed in 3.7%, 8.9%, 2.3%, and 0.6% of total cases, respectively. A multivariate analysis showed no significant increase in infection with ICS use (odds ratio, 0.84; 95% confidence interval, 0.66-1.03). Moreover, there were no associations between the positivity of infection and the dose or type of ICS prescribed. CONCLUSION Prior ICS use did not increase the positivity for SARS-CoV-2 infection. Moreover, different doses or types of ICS did not affect this positivity.
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Affiliation(s)
- Sang Chul Lee
- Division of Pulmonology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kang Ju Son
- Department of Research and Analysis, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
- Department of Biostatistics and Computing, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Chang Hoon Han
- Division of Pulmonology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seon Cheol Park
- Division of Pulmonology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
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13
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Cazzola M, Rogliani P, Laitano R, Calzetta L, Matera MG. Beyond Dual Bronchodilation – Triple Therapy, When and Why. Int J Chron Obstruct Pulmon Dis 2022; 17:165-180. [PMID: 35068929 PMCID: PMC8766250 DOI: 10.2147/copd.s345263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Although pharmacological treatment of COPD is codified in different guidelines and strategy documents, there is abundant evidence of discrepancy between what they suggest and what health professionals prescribe, especially in low-risk groups where there is widespread overprescription of triple therapy. It is therefore necessary to clarify when the use of triple therapy is indicated in COPD patients and when it is preferable to maintain treatment with dual bronchodilation. In this article, we discuss our views based on our experience and what is reported in the literature and try to give answers to these two questions. The evidence generated by pivotal RCTs supports the use of triple therapy in patients who present for the first time and have severe airway obstruction, are symptomatic, have had frequent moderate or severe exacerbations in the previous year, and have peripheral eosinophilia. However, it is difficult to determine whether step-up is useful in all other cases because the available data are quite conflicting. It is likely that the inconsistency in the information generated by the various available studies may explain the prescribing behaviour of many physicians who do not adhere to recommendations of guidelines and strategies. However, it is necessary to establish whether and when the addition of an ICS to the LAMA/LABA combination is effective, to determine whether triple therapy can induce an additional clinical benefit over dual bronchodilation, irrespective of a preventive effect on COPD exacerbations, to establish its value, and to examine whether cost differences can support the use of triple therapy over combined LAMA/LABA therapy in real life.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
- Correspondence: Mario Cazzola Email
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Rossella Laitano
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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14
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Choi JH, Jeong KB, Park YH, Yu I, Lee SJ, Lee MK, Kim SH, Lee WY, Yong SJ, Lee JH. Comparison of Risk of Pneumonia Caused by Fluticasone Propionate versus Budesonide in Chronic Obstructive Pulmonary Disease: A Nationwide Retrospective Cohort Study. Int J Chron Obstruct Pulmon Dis 2021; 16:3229-3237. [PMID: 34858023 PMCID: PMC8629914 DOI: 10.2147/copd.s332151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/14/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Inhaled corticosteroids (ICSs) play an important role in lowering the risk of acute exacerbation of chronic obstructive pulmonary disease (COPD). However, ICSs are known to increase the risk of pneumonia. Moreover, previous studies have shown that the incidence rate of pneumonia varies depending on the type of ICS. In this study, the risk of pneumonia according to the type of ICS was investigated in a population-based cohort. Methods A retrospective cohort study was conducted using claims data of the entire population from the Korean National Health Insurance Service. Patients who were newly diagnosed with COPD and prescribed fluticasone propionate or budesonide were enrolled as study subjects. Cumulative doses of ICSs were classified into categorical variables to analyze the risk of pneumonia within identical ICS doses. Results A total of 47,473 subjects were identified and allocated as 14,518 fluticasone propionate and 14,518 budesonide users through 1:1 propensity score matching. Fluticasone propionate users were more likely to develop pneumonia than budesonide users (14.22% vs 10.66%, p<0.0001). The incidence rate per 100,000 person-years was 2,914.77 for fluticasone propionate users and 2,102.90 for budesonide users. The hazard ratio (HR) of pneumonia in fluticasone propionate compared to budesonide was 1.34 (95% CI 1.26–1.43, p<0.0001). The risk of pneumonia for fluticasone propionate compared to budesonide increased with higher ICS cumulative doses: 1.06 (0.93–1.21), 1.41 (1.19–1.66), 1.41 (1.23–1.63), and 1.49 (1.33–1.66) from the lowest to highest quartiles, respectively. Conclusion ICS types and doses need to be carefully considered during treatment with ICSs in patients with COPD.
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Affiliation(s)
- Jae-Hwa Choi
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Keun-Bae Jeong
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - You Hyun Park
- Department of Biostatistics, Yonsei University, Seoul, Korea
| | - Iseul Yu
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Jeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Myoung Kyu Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang-Ha Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Suk Joong Yong
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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15
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Tomaich A, Klatt S, Nagy MW. Narrative Literature Review Guided Approach of Inhaled Corticosteroid de-escalation in Chronic Obstructive Pulmonary Disease. J Pharm Pract 2021; 36:628-639. [PMID: 34697964 DOI: 10.1177/08971900211053771] [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: 11/17/2022]
Abstract
OBJECTIVE To review the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report recommendations and create an algorithm to assist clinicians in determining which chronic obstructive pulmonary disease (COPD) patients qualify for inhaled corticosteroid (ICS) de-escalation. Data Sources: A literature search of MEDLINE/PubMed from 2002 to August 2021 was conducted using the search terms inhaled corticosteroids, chronic obstructive pulmonary disease, and de-escalation and review of the reference lists of identified articles for pertinent citations. STUDY SELECTION AND DATA EXTRACTION Relevant studies and articles were included if they focused on the utilization of ICS in COPD. DATA SYNTHESIS The 2020 GOLD report only recommends triple therapy with ICS, long acting beta agonists, and long acting muscarinic antagonists for patients with frequent exacerbations, frequent hospitalizations, or elevated blood eosinophil counts. Despite this clear framework, patients are prescribed ICS without these characteristics. Available evidence suggests that these patients can be de-escalated from ICS therapy without concern for worsening lung function or exacerbations. Relevance to Patient Care and Clinical Practice: Patients with COPD may be experiencing more risk than benefit on ICS therapy. Clinicians should be knowledgeable on how to evaluate patient therapy for appropriateness and know how to safely deprescribe ICS given their limited efficacy in many COPD patients. CONCLUSION There remains no specific guidance on how to de-escalate patients off an ICS when the therapy is not indicated. Use of clinical evidence with stepwise algorithms can be models to approach de-escalation of ICS in patients with COPD.
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Affiliation(s)
- Anamarie Tomaich
- Medical College of Wisconsin School of Pharmacy, Milwaukee WI, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee WI, USA
| | - Shawnee Klatt
- Medical College of Wisconsin School of Pharmacy, Milwaukee WI, USA.,Ascension St Joseph Hospital, Milwaukee WI, USA
| | - Michael W Nagy
- Medical College of Wisconsin School of Pharmacy, Milwaukee WI, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee WI, USA
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16
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An Obvious Paradigm: Choosing Bronchodilators and Inhaled Corticosteroids for Their Pharmacologic Characteristics. Chest 2021; 160:1157-1159. [PMID: 34625159 DOI: 10.1016/j.chest.2021.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 11/24/2022] Open
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17
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Leitao Filho FS, Takiguchi H, Akata K, Ra SW, Moon JY, Kim HK, Cho Y, Yamasaki K, Milne S, Yang J, Yang CWT, Li X, Nislow C, van Eeden SF, Shaipanich T, Lam S, Leung JM, Sin DD. Effects of Inhaled Corticosteroid/long-acting beta-2 Agonist Combination on the Airway Microbiome of Patients with COPD: A Randomized Controlled Trial (DISARM). Am J Respir Crit Care Med 2021; 204:1143-1152. [PMID: 34464242 DOI: 10.1164/rccm.202102-0289oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Inhaled corticosteroids (ICS) are commonly prescribed with long-acting beta-2 agonists (LABA) in COPD. To date, the effects of ICS therapy on the airway microbiome in COPD are unknown. OBJECTIVES To determine the effects of ICS/LABA on the airway microbiome of COPD patients. METHODS Clinically stable COPD patients were enrolled into a 4-week run-in period during which ICS was discontinued and all participants were placed on formoterol 12 µg twice daily (BID). The participants were then randomized to: budesonide/formoterol (Bud + Form; 400/12 µg BID), fluticasone/salmeterol (Flu + Salm; 250/50 µg BID) or formoterol only (Form; 12 µg BID) for 12 weeks. Participants underwent bronchoscopy before and after the 12-week treatment period. The primary endpoint was the comparison of changes in the airway microbiome over the trial period between the ICS/LABA and LABA-only groups. MEASUREMENTS AND MAIN RESULTS 63 participants underwent randomization: Bud + Form (n=20), Flu + Salm (n=22) and Form (n=21) groups; 56 subjects completed all visits. After the treatment period, changes in alpha diversity were significantly different across groups, especially between Flu + Salm and Form groups (Δ richness: p = 0.02; Δ Shannon Index: p = 0.03). Longitudinal differential abundance analyses revealed more pronounced microbial shifts from baseline in the fluticasone (vs. budesonide or formoterol only) group. CONCLUSIONS Fluticasone-based ICS/LABA therapy modifies the airway microbiome in COPD, leading to a relative reduction in alpha diversity and a greater number of bacterial taxa changes. These data may have implications in patients who develop pneumonia on ICS. Clinical trial registration available at www.clinicaltrials.gov, ID:NCT02833480.
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Affiliation(s)
- Fernando Sergio Leitao Filho
- The University of British Columbia, 8166, Department of Medicine (Division of Respiratory Medicine), Vancouver, British Columbia, Canada
| | - Hiroto Takiguchi
- The University of British Columbia, 8166, Department of Medicine (Division of Respiratory Medicine), Vancouver, British Columbia, Canada
| | - Kentaro Akata
- University of Occupational and Environmental Health Japan, 13137, Respiratory Medicine, Kitakyushu, Japan
| | - Seung Won Ra
- University of Ulsan College of Medicine, 37994, Medicine, Ulsan, Korea (the Republic of)
| | - Ji-Yong Moon
- Hanyang University, 26716, Seongdong-gu, Korea (the Republic of)
| | - Hyun Kuk Kim
- Inje University Haeundae Paik Hospital, 222187, Busan, Korea (the Republic of)
| | - Yuji Cho
- Gyeongsang National University Hospital, Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Jinju, Korea (the Republic of)
| | - Kei Yamasaki
- University of Occupational and Environmental Health, Japan, Respiratory Medicine, Kitakyushu, Japan
| | - Stephen Milne
- The University of British Columbia, 8166, Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada.,The University of British Columbia, 8166, Division of Respiratory Medicine, Vancouver, British Columbia, Canada
| | - Julia Yang
- St. Paul's Hospital, University of British Columbia, Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada
| | - Cheng Wei Tony Yang
- The University of British Columbia, 8166, Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, British Columbia, Canada.,Providence Health Care, 173031, Providence Airway Centre, Vancouver, British Columbia, Canada
| | - Xuan Li
- The University of British Columbia, 8166, Centre for Heart Lung Innovation, St. Paul's Hospital, & Department of Medicine (Division of Respiratory Medicine), Vancouver, British Columbia, Canada
| | - Corey Nislow
- The University of British Columbia, 8166, Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada
| | | | - Tawimas Shaipanich
- Division of Respiratory Medicine, Medicine, Vancouver, British Columbia, Canada
| | - Stephen Lam
- British Columbia Cancer Research Centre, Integrative Oncology, Vancouver, British Columbia, Canada
| | - Janice M Leung
- National Institutes of Health, Critical Care Medicine Department, Bethesda, Maryland, United States
| | - Don D Sin
- University of Alberta, 3158, Medicine, Edmonton, Alberta, Canada;
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18
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Comparative Effectiveness and Safety of Different Types of Inhaled Long-Acting β 2-Agonist Plus Inhaled Long-Acting Muscarinic Antagonist vs Inhaled Long-Acting β 2-Agonist Plus Inhaled Corticosteroid Fixed-Dose Combinations in COPD A Propensity Score-Inverse Probability of Treatment Weighting Cohort Study. Chest 2021; 160:1255-1270. [PMID: 34023320 DOI: 10.1016/j.chest.2021.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Despite multiple available fixed-dose combinations (FDCs) of inhaled long-acting β2-agonists (LABAs) plus long-acting muscarinic antagonists (LAMAs) and LABAs plus inhaled corticosteroids (ICS) for COPD, uncertainty remains regarding their comparative effects. RESEARCH QUESTION Can comparative effectiveness and safety of LABA plus LAMA (LABA/LAMA) and LABA plus ICS (LABA/ICS) FDCs vary by different individual components of the dual combinations in COPD? STUDY DESIGN AND METHODS We conducted a new user, propensity score-inverse probability of treatment weighting cohort study to compare the effectiveness and safety of two frequently used LABA/LAMA FDCs (indacaterol plus glycopyrronium [IND/GLY] and vilanterol plus umeclidinium [VI/UMEC]) vs three commonly prescribed LABA/ICS FDCs (salmeterol plus fluticasone propionate [SAL/FP], formoterol fumarate plus budesonide [FF/BUD], and formoterol fumarate plus beclomethasone dipropionate [FF/BDP]) using the Taiwanese nationwide health-care claims from 2014 through 2017. The primary effectiveness outcome was the annual moderate to severe exacerbation rate, and safety outcomes included risks of severe pneumonia and cardiovascular disease requiring hospitalization. Weighted generalized linear mixed models and Cox proportional hazard models were used to assess the effectiveness and safety outcomes, respectively. RESULTS Patients with COPD initiating IND/GLY and VI/UMEC showed an 11% (incidence rate ratio [IRR], 0.89; 95% CI, 0.80-0.98) and 20% (IRR, 0.80; 95% CI, 0.71-0.90) reduced annual rate of moderate to severe exacerbations, respectively, than those initiating SAL/FP, but showed a similar rate as those initiating FF/BUD or FF/BDP. Both LABA/LAMA FDCs, compared with SAL/FP and VI/UMEC vs FF/BDP, were associated with a 27% (hazard ratio [HR], 0.73; 95% CI, 0.59-0.90) to 42% (HR, 0.58; 95% CI, 0.48-0.70) reduced pneumonia risk. Cardiovascular risk was comparable in five groups. An intraclass difference existed in rates of moderate to severe COPD exacerbation and risks of pneumonia among LABA/ICS FDCs, but not between LABA/LAMA FDCs. INTERPRETATION Both LABA/LAMAs vs SAL/FP are associated with a lower exacerbation rate and pneumonia risk, but exhibit similar effectiveness and safety outcomes compared with FF/BDP or FF/BUD, suggesting that comparative effects may differ by individual components of the dual therapies in COPD.
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19
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Beneficial Immunomodulatory Effects of Fluticasone Propionate in Chlamydia pneumoniae-Infected Mice. Pathogens 2021; 10:pathogens10030338. [PMID: 33799333 PMCID: PMC8001673 DOI: 10.3390/pathogens10030338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/02/2021] [Accepted: 03/12/2021] [Indexed: 12/01/2022] Open
Abstract
The associations between inhaled corticosteroid (ICS) use and pulmonary infections remains controversial. Chlamydia pneumoniae (C. pneumoniae) accounts for asthma exacerbations; however, there are no data regarding ICS effects on C. pneumoniae infections. Thus, we investigated whether fluticasone propionate (FP) or budesonide (BUD) could affect C. pneumoniae infection in vitro and in vivo, focusing on the possible mechanisms that lead to potential anti-chlamydial outcomes. We performed direct qPCR to detect C. pneumoniae growth in infected, FP-treated, and BUD-treated A549 cells. Furthermore, FP or BUD was administered by inhalation to C. pneumoniae-infected mice. The recoverable C. pneumoniae was determined by indirect immunofluorescence. Expression levels of interferon (IFN)-γ and IFN-γ inducible chemokines were assessed by qPCR. We measured the protein concentrations of IFN-γ and of other cytokines that potentially participate in the anti-chlamydial response by ELISA. We found that FP treatment suppressed Chlamydia growth in A549 cells and in mice. Higher levels of IFN-γ gene expression were observed in FP-treated mice compared to the untreated and BUD-treated mice (p < 0.0001). IFN-γ and anti-chlamydial protein MIG/CXCL9 values were significantly higher after FP inhalation. Collectively, FP, but not BUD, suppressed C. pneumoniae growth in vitro and in vivo, which was likely due to the enhanced IFN-γ related responses.
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20
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Hartmann JE, Albrich WC, Dmitrijeva M, Kahlert CR. The Effects of Corticosteroids on the Respiratory Microbiome: A Systematic Review. Front Med (Lausanne) 2021; 8:588584. [PMID: 33777968 PMCID: PMC7988087 DOI: 10.3389/fmed.2021.588584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Since its discovery, the respiratory microbiome has been implicated in the pathogenesis of multiple pulmonary diseases. Even though corticosteroid treatments are widely prescribed for pulmonary diseases, their effects on the respiratory microbiome are still poorly understood. This systematic review summarizes the current understanding of the effects of corticosteroids on the microbiome of the airways. Research Question: How does treatment with corticosteroids impact the respiratory microbiome? Study Design and Methods: According to the PRISMA guidelines, Embase, Medline, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for all observational or randomized-controlled studies comparing the microbiome parameters of patients receiving corticosteroids to those of controls. The primary outcomes of interest were changes in the diversity, composition and total burden of the respiratory microbiome as assessed by culture-independent molecular methods. Results: Out of 1,943 identified reports, five studies could be included: two on patients with asthma, two on patients with chronic obstructive pulmonary disease and one on patients with chronic rhinosinusitis. The studies were highly heterogeneous with regards to the methods used and the populations investigated. Microbiome diversity increased with corticosteroids at least transiently in three studies and decreased in one study. The effects of corticosteroids on the composition of the respiratory microbiome were significant but without a clear shared direction. A significant increase in microbial burden after corticosteroids was seen in one study. Interpretation: Data on the effect of corticosteroids on the respiratory microbiome are still limited, with considerable heterogeneity between studies. However, available data suggest that corticosteroid treatment may have significant effects on the composition and possibly the diversity of the respiratory microbiome. Further research is needed to better understand the influence of corticosteroids on the respiratory microbiome and thus better target its widespread therapeutic use.
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Affiliation(s)
- Julia E. Hartmann
- Division of Infectious Diseases/Hospital Epidemiology, Kantonsspital St. Gallen, St.Gallen, Switzerland
| | - Werner C. Albrich
- Division of Infectious Diseases/Hospital Epidemiology, Kantonsspital St. Gallen, St.Gallen, Switzerland
| | - Marija Dmitrijeva
- Department of Molecular Life Sciences, University of Zurich, Zurich, Switzerland
- Swiss Institute of Bioinformatics, Zurich, Switzerland
| | - Christian R. Kahlert
- Division of Infectious Diseases/Hospital Epidemiology, Kantonsspital St. Gallen, St.Gallen, Switzerland
- Division of Infectious Diseases/Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
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21
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Yasuda K, Kubo Y, Murata H, Sakamoto K. Cortisol promotes stress tolerance via DAF-16 in Caenorhabditis elegans. Biochem Biophys Rep 2021; 26:100961. [PMID: 33732902 PMCID: PMC7944026 DOI: 10.1016/j.bbrep.2021.100961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/27/2020] [Accepted: 02/17/2021] [Indexed: 01/09/2023] Open
Abstract
In this study, we studied the effects of cortisol and cortisone on the age-related decrease in locomotion in the nematode Caenorhabditis elegans and on the tolerance to heat stress at 35 °C and to oxidative stress induced by the exposure to 0.1% H2O2. Changes in mRNA expression levels of C. elegans genes related to stress tolerance were also analyzed. Cortisol treatment restored nematode movement following heat stress and increased viability under oxidative stress, but also shortened worm lifespan. Cortisone, a cortisol precursor, also restored movement after heat stress. Additionally, cortisol treatment increased mRNA expression of the hsp-12.6 and sod-3 genes. Furthermore, cortisol treatment failed to restore movement of daf-16-deficient mutants after heat stress, whereas cortisone failed to restore the movement of dhs-30-deficient mutants after heat stress. In conclusion, the results suggested that cortisol promoted stress tolerance via DAF-16 but shortened the lifespan, whereas cortisone promoted stress tolerance via DHS-30. Cortisol promoted anti-aging, heat and oxidative stress tolerance but shorten life span •Cortisone promoted anti-aging and heat stress tolerance •Heat and oxidative stress tolerance induced by cortisol depended on DAF-16 and SKN-1, respectively. •Cortisone was converted to cortisol via DHS-30
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Affiliation(s)
| | | | | | - Kazuichi Sakamoto
- Corresponding author. Faculty of Life and Environmental Sciences, University of Tsukuba, Tennoudai 1-1-1, Tsukuba, Ibaraki, 305-8572, Japan.
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22
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Kendzerska T, Aaron SD, To T, Licskai C, Stanbrook MB, Hogan ME, Tan WC, Bourbeau J, Gershon AS. Effect of type and dosage of newly prescribed inhaled corticosteroids on obstructive lung disease and pneumonia hospitalisations in older individuals with asthma, COPD or both: a retrospective study of health administrative data. Eur Respir J 2021; 57:13993003.02585-2020. [PMID: 32703774 DOI: 10.1183/13993003.02585-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/05/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Tetyana Kendzerska
- Dept of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada .,ICES, Ottawa, ON, Canada
| | - Shawn D Aaron
- Dept of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Teresa To
- The Hospital for Sick Children, Research Institute, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Dalla Lana School of Public Health, Toronto, ON, Canada
| | - Chris Licskai
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Matthew B Stanbrook
- ICES, Toronto, ON, Canada.,Dept of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Wan C Tan
- University of British Columbia, Vancouver, BC, Canada
| | - Jean Bourbeau
- McGill University, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Andrea S Gershon
- The Hospital for Sick Children, Research Institute, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Dalla Lana School of Public Health, Toronto, ON, Canada.,Dept of Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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23
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The airways microbiome of individuals with asthma treated with high and low doses of inhaled corticosteroids. PLoS One 2020; 15:e0244681. [PMID: 33378384 PMCID: PMC7773270 DOI: 10.1371/journal.pone.0244681] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/08/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are the mainstay of asthma treatment, but evidence suggests a link between ICS usage and increased rates of respiratory infections. We assessed the composition of the asthmatic airways microbiome in asthma patients taking low and high dose ICS and the stability of the microbiome over a 2 week period. METHODS We prospectively recruited 55 individuals with asthma. Of these, 22 were on low-dose ICS and 33 on high-dose ICS (16 on budesonide, 17 on fluticasone propionate). Sputum from each subject underwent DNA extraction, amplification and 16S rRNA gene sequencing of the bacterial component of the microbiome. 19 subjects returned for further sputum induction after 24 h and 2 weeks. RESULTS A total of 5,615,037 sequencing reads revealed 167 bacterial taxa in the asthmatic airway samples, with the most abundant being Streptococcus spp. No significant differences in sputum bacterial load or overall community composition were seen between the low- and high-dose ICS groups. However, Streptococcus spp. showed significantly higher relative abundance in subjects taking low-dose ICS (p = 0.002). Haemophilus parainfluenzae was significantly more abundant in subjects on high-dose fluticasone propionate than those on high-dose budesonide (p = 0.047). There were no statistically significant changes in microbiota composition over a 2-week period. DISCUSSION Whilst no significant differences were observed between the low- and high-dose ICS groups, increased abundance of the potential pathogen H. parainfluenzae was observed in patients taking high-dose fluticasone propionate compared to those taking high-dose budesonide. The microbiota were stable over fourteen days, providing novel evidence of the established community of bacteria in the asthmatic airways. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02671773.
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24
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Lee JH, Park YH, Kang DR, Lee SJ, Lee MK, Kim SH, Yong SJ, Lee WY. Risk of Pneumonia Associated with Inhaled Corticosteroid in Patients with Chronic Obstructive Pulmonary Disease: A Korean Population-Based Study. Int J Chron Obstruct Pulmon Dis 2020; 15:3397-3406. [PMID: 33402820 PMCID: PMC7778438 DOI: 10.2147/copd.s286149] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Inhaled corticosteroids (ICSs) are recommended for patients with frequent exacerbation of chronic obstructive pulmonary disease (COPD). However, accumulating evidence has indicated the risk of pneumonia from the use of ICS. This study aimed to investigate the association between ICS and pneumonia in the real-world clinical setting. Methods A retrospective cohort study was performed using nationwide population data from the Korea National Health Insurance Service. Subjects who had a new diagnosis of COPD and who received inhaled bronchodilators without a diagnosis of pneumonia before the initiation of bronchodilators were identified. Subjects were followed up until their first diagnosis of pneumonia. The risk of pneumonia in ICS users was compared to that in non-ICS users. Results A total of 87,594 subjects were identified and 1:1 matched to 22,161 ICS users and non-ICS users. More ICS users were diagnosed with pneumonia compared to non-ICS users (33.73% versus 24.51%, P<0.0001). The incidence rate per 100,000 person-years was 8904.98 for ICS users and 6206.79 for non-ICS users. The hazard ratio (HR) of pneumonia for ICS users was 1.62 (95% CI 1.54–1.70). The HR of subjects prescribed with the lowest ICS cumulative dose was 1.35 (1.27–1.43). The HR increased to 1.51 (1.42–1.60), 1.96 (1.85–2.09), and 2.03 (1.89–2.18) as the cumulative dose increased. Pneumonia was strongly associated with fluticasone propionate (1.79 (1.70–1.89)) and fluticasone furoate (1.80 (1.61–2.01)) use, compared to the use of other types of ICS. Conclusion ICS increases the risk of pneumonia in patients with COPD. Hence, ICS should be carefully prescribed in patients with risk factors for pneumonia while considering the cumulative doses and subtypes of ICS.
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Affiliation(s)
- Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - You Hyun Park
- Department of Biostatistics, Yonsei University, Seoul, Korea
| | - Dae Ryong Kang
- Department of Precision Medicine & Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Jeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Myoung Kyu Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang-Ha Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Suk Joong Yong
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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25
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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: 15] [Impact Index Per Article: 3.0] [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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26
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Papaioannou AI, Loukides S, Bakakos P, Kosmas EN, Rovina N, Steiropoulos P, Fouka E, Hillas G, Patentalakis G, Kouvela M, Tzanakis N. Dual Bronchodilator in the Era of Triple Therapy. Int J Chron Obstruct Pulmon Dis 2020; 15:2695-2705. [PMID: 33149567 PMCID: PMC7604249 DOI: 10.2147/copd.s273987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/23/2020] [Indexed: 01/18/2023] Open
Abstract
Pharmacological medications used for the treatment of COPD patients have increased significantly. Long-acting bronchodilators have been recognized as the mainstay of the treatment of stable COPD, while ICS are usually added in patients with COPD who experience exacerbations, despite bronchodilator treatment. In the latest years, several studies have been published showing the beneficial effect of adding ICS on dual bronchodilation in patients suffering from more severe disease comparing triple therapy with several therapeutic regiments including dual bronchodilation and providing a message that this triple therapy might be more appropriate for COPD patients. However, not all COPD patients have a desirable response to ICS treatment while long-term ICS use in COPD is associated with several side effects. In this report, we aimed to provide a review of the current knowledge on the importance of dual bronchodilation on COPD patients and to compare its use with triple therapy, by covering a wide spectrum of topics. Finally, we propose an algorithm on performing treatment step up from dual bronchodilation to triple therapy and step down from triple to double bronchodilation considering the current evidence.
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Affiliation(s)
- Andriana I Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Petros Bakakos
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | | | - Nikoletta Rovina
- 1st Respiratory Medicine Department, University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangellia Fouka
- Respiratory Medicine Department, Aristotle University of Thessaloniki, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Georgios Hillas
- 5th Respiratory Medicine Department, Sotiria Chest Hospital, Athens, Greece
| | | | - Marousa Kouvela
- 3rd Department of Medicine, Athens Medical School, Athens, Greece
| | - Nikos Tzanakis
- Department of Thoracic Medicine, Faculty of Medicine, University of Crete, Crete, Greece
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27
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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: 0.2] [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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Matera MG, Page CP, Calzetta L, Rogliani P, Cazzola M. Pharmacology and Therapeutics of Bronchodilators Revisited. Pharmacol Rev 2020; 72:218-252. [PMID: 31848208 DOI: 10.1124/pr.119.018150] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Bronchodilators remain the cornerstone of the treatment of airway disorders such as asthma and chronic obstructive pulmonary disease (COPD). There is therefore considerable interest in understanding how to optimize the use of our existing classes of bronchodilator and in identifying novel classes of bronchodilator drugs. However, new classes of bronchodilator have proved challenging to develop because many of these have no better efficacy than existing classes of bronchodilator and often have unacceptable safety profiles. Recent research has shown that optimization of bronchodilation occurs when both arms of the autonomic nervous system are affected through antagonism of muscarinic receptors to reduce the influence of parasympathetic innervation of the lung and through stimulation of β 2-adrenoceptors (β 2-ARs) on airway smooth muscle with β 2-AR-selective agonists to mimic the sympathetic influence on the lung. This is currently achieved by use of fixed-dose combinations of inhaled long-acting β 2-adrenoceptor agonists (LABAs) and long-acting muscarinic acetylcholine receptor antagonists (LAMAs). Due to the distinct mechanisms of action of LAMAs and LABAs, the additive/synergistic effects of using these drug classes together has been extensively investigated. More recently, so-called "triple inhalers" containing fixed-dose combinations of both classes of bronchodilator (dual bronchodilation) and an inhaled corticosteroid in the same inhaler have been developed. Furthermore, a number of so-called "bifunctional drugs" having two different primary pharmacological actions in the same molecule are under development. This review discusses recent advancements in knowledge on bronchodilators and bifunctional drugs for the treatment of asthma and COPD. SIGNIFICANCE STATEMENT: Since our last review in 2012, there has been considerable research to identify novel classes of bronchodilator drugs, to further understand how to optimize the use of the existing classes of bronchodilator, and to better understand the role of bifunctional drugs in the treatment of asthma and chronic obstructive pulmonary disease.
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Affiliation(s)
- M G Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - C P Page
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - L Calzetta
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - P Rogliani
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - M Cazzola
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
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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: 2.4] [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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30
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Hespanhol V, Bárbara C. Pneumonia mortality, comorbidities matter? Pulmonology 2020; 26:123-129. [DOI: 10.1016/j.pulmoe.2019.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 10/11/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022] Open
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31
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Hanania NA, Papi A, Anzueto A, Martinez FJ, Rossman KA, Cappelletti CS, Duncan EA, Nyberg JS, Dorinsky PM. Efficacy and safety of two doses of budesonide/formoterol fumarate metered dose inhaler in COPD. ERJ Open Res 2020; 6:00187-2019. [PMID: 32363206 PMCID: PMC7184113 DOI: 10.1183/23120541.00187-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/19/2020] [Indexed: 11/09/2022] Open
Abstract
Inhaled corticosteroid/long-acting β2-agonist combination therapy is a recommended treatment option for patients with chronic obstructive pulmonary disease (COPD) and increased exacerbation risk, particularly those with elevated blood eosinophil levels. SOPHOS (NCT02727660) evaluated the efficacy and safety of two doses of budesonide/formoterol fumarate dihydrate metered dose inhaler (BFF MDI) versus formoterol fumarate dihydrate (FF) MDI, each delivered using co-suspension delivery technology, in patients with moderate-to-very severe COPD and a history of exacerbations. In this phase 3, randomised, double-blind, parallel-group, 12–52-week, variable length study, patients received twice-daily BFF MDI 320/10 µg or 160/10 µg, or FF MDI 10 µg. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) at week 12. Secondary and other endpoints included assessments of moderate/severe COPD exacerbations and safety. The primary analysis (modified intent-to-treat) population included 1843 patients (BFF MDI 320/10 µg, n=619; BFF MDI 160/10 µg, n=617; and FF MDI, n=607). BFF MDI 320/10 µg and 160/10 µg improved morning pre-dose trough FEV1 at week 12 versus FF MDI (least squares mean differences 34 mL [p=0.0081] and 32 mL [p=0.0134], respectively), increased time to first exacerbation (hazard ratios 0.827 [p=0.0441] and 0.803 [p=0.0198], respectively) and reduced exacerbation rate (rate ratios 0.67 [p=0.0001] and 0.71 [p=0.0010], respectively). Lung function and exacerbation benefits were driven by patients with blood eosinophil counts ≥150 cells·mm−3. The incidence of adverse events was similar, and pneumonia rates were low (≤2.4%) across treatments. SOPHOS demonstrated the efficacy and tolerability of BFF MDI 320/10 µg and 160/10 µg in patients with moderate-to-very severe COPD at increased risk of exacerbations. Co-suspension delivery technology budesonide/formoterol fumarate metered dose inhaler improve lung function and reduce exacerbation risk versus LABA monotherapy in patients with moderate to very severe COPD and an exacerbation history in the prior yearhttp://bit.ly/3aDOvru
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Affiliation(s)
- Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alberto Papi
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonio Anzueto
- Pulmonary Medicine and Critical Care, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Fernando J Martinez
- Joan and Sanford I. Weill Dept of Medicine, Weill Cornell Medicine, New York, NY, USA
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32
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Mapel DW, Roberts MH, Davis J. Budesonide/formoterol therapy: effective and appropriate use in asthma and chronic obstructive pulmonary disease. J Comp Eff Res 2020; 9:231-251. [PMID: 31983228 DOI: 10.2217/cer-2019-0161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Quality, real-world comparative effectiveness (CE) studies of asthma and chronic obstructive pulmonary disease therapy efficacy are scarce. We identified and evaluated peer-reviewed CE and appropriate-use evaluations of budesonide/formoterol combination (BFC) maintenance therapy. Materials & methods: Analyses were limited to retrospective, real-world utilization studies of BFC delivered by pressurized metered-dose inhalers. Results: In a CE study of BFC versus fluticasone/salmeterol combinations (FSC) in asthma, BFC users had fewer total exacerbations. In appropriate-use studies of asthma treatment, BFC patients were consistently more likely to meet treatment escalation recommendations. BFC comparisons with FSC or tiotropium for chronic obstructive pulmonary disease found differences in exacerbation rates and rescue inhaler use. Conclusion: We found available, good quality BFC CE and appropriate-use articles; however, all had limitations.
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Affiliation(s)
- Douglas W Mapel
- University of New Mexico College of Pharmacy, MSC09 5360, University of New Mexico, Albuquerque, NM 87131, USA.,LCF Research, 2309 Renard Place SE Ste 103, Albuquerque, NM 87106, USA
| | - Melissa H Roberts
- University of New Mexico College of Pharmacy, MSC09 5360, University of New Mexico, Albuquerque, NM 87131, USA
| | - Jill Davis
- AstraZeneca LP, 1800 Concord Pike, Wilmington, DE 19897, USA
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Baha A, Kokturk N, Bahcecioglu SN, Yapar D, Aksakal N, Gündüz C, Tasbakan S, Sayiner A, Coskun AS, Durmaz F, Cilli A, Celenk B, Kılınc O, Salman S, Hazar A, Tokgoz F. The effect of inhaled corticosteroids in the outcomes of community-acquired pneumonia: ICCAP study (TURKCAP Database). CLINICAL RESPIRATORY JOURNAL 2020; 14:397-404. [PMID: 31908143 DOI: 10.1111/crj.13145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/18/2019] [Accepted: 01/02/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We aimed to investigate the effect of inhaled corticosteroids (ICS) in the outcomes of community-acquired pneumonia (CAP), as well as to determine if ICS usage is exist among the risk factors for mortality in those patients. MATERIALS AND METHODS In this retrospective cross-sectional multicentre study, 1069 hospitalised CAP patients were investigated using CAP Database of Turkish Thoracic Society (TURKCAP Database). The patients were divided into two groups, depending on their ICS use. The data were analysed by appropriate statistical methods. RESULTS 172 (75.8%) of the 227 patients who were on ICS had COPD and 37 (16.3%) had asthma. There were fewer patients with fever among ICS-users compared to non-ICS users (P = 0.013), and less muscle pain (P = 0.015) and fewer GIS symptoms (P = 0.022). No statistically significant difference was found between ICS use/ type of ICS and the duration of hospitalisation (P = 0.286). The multivariate regression analysis showed that patients using ICS had lower body temperature and, less crackles/bronchial sound. In the multivariate logistic regression model lung cancer (OR: 6.75), glucose (OR: 1.01) and CURB-65 (OR: 1.72) were significantly associated with mortality in the CAP patients. ICS usage were not found to be associated with mortality. CONCLUSION The use of ICS by the patients with CAP admitted to the hospital is not independently related with any radiological pattern, hospitalisation duration and mortality. ICS usage may diminish fever response and may suppress the findings of crackles and/or bronchial sounds. This needs further confirmation.
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Affiliation(s)
- Ayse Baha
- Department of Pulmonary Diseases, Akcicek State Hospital, Kyrenia, Cyprus
| | - Nurdan Kokturk
- Department of Pulmonary Diseases, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sakine Nazik Bahcecioglu
- Department of Allergy Immunology and Pulmonary Diseases, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Dilek Yapar
- Department of Public Health, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nur Aksakal
- Department of Public Health, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Canan Gündüz
- Department of Pulmonary Diseases, Ege University Faculty of Medicine, Izmir, Turkey
| | - Sezai Tasbakan
- Department of Pulmonary Diseases, Ege University Faculty of Medicine, Izmir, Turkey
| | - Abdullah Sayiner
- Department of Pulmonary Diseases, Ege University Faculty of Medicine, Izmir, Turkey
| | - Aysin Sakar Coskun
- Department of Pulmonary Diseases, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Feride Durmaz
- Department of Pulmonary Diseases, Sureyyapasa Education and Research Hospital, Istanbul, Turkey
| | - Aykut Cilli
- Department of Pulmonary Diseases, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Burcu Celenk
- Department of Pulmonary Diseases, Antalya Atatürk Training and Research Hospital, Antalya, Turkey
| | - Oguz Kılınc
- Department of Pulmonary Diseases, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Seda Salman
- Department of Pulmonary Diseases, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Armagan Hazar
- Department of Pulmonary Diseases, Sureyyapasa Education and Research Hospital, Istanbul, Turkey
| | - Fatma Tokgoz
- Department of Chest Diseases, Canakkale State Hospital, Canakkale, Turkey
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Huang HL, Lee MR, Liu CJ, Cheng MH, Lu PL, Wang JY, Chong IW. Predictors of radiographic progression for NTM–pulmonary disease diagnosed by bronchoscopy. Respir Med 2020; 161:105847. [DOI: 10.1016/j.rmed.2019.105847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/09/2019] [Accepted: 11/22/2019] [Indexed: 12/27/2022]
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Ekbom E, Quint J, Schöler L, Malinovschi A, Franklin K, Holm M, Torén K, Lindberg E, Jarvis D, Janson C. Asthma and treatment with inhaled corticosteroids: associations with hospitalisations with pneumonia. BMC Pulm Med 2019; 19:254. [PMID: 31856764 PMCID: PMC6923948 DOI: 10.1186/s12890-019-1025-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Emil Ekbom
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Jennifer Quint
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College, London, UK
| | - Linus Schöler
- Department of Occupational and Environmental Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Karl Franklin
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Mathias Holm
- Department of Occupational and Environmental Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Kjell Torén
- Department of Occupational and Environmental Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Deborah Jarvis
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College, London, UK
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College, London, UK
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Abstract
Airway inflammation is a major contributing factor in both asthma and chronic obstructive pulmonary disease (COPD) and represents an important target for treatment. Inhaled corticosteroids (ICS) as monotherapy or in combination therapy with long-acting β2-agonists or long-acting muscarinic antagonists are used extensively in the treatment of asthma and COPD. The development of ICS for their anti-inflammatory properties progressed through efforts to increase topical potency and minimise systemic potency and through advances in inhaled delivery technology. Budesonide is a potent, non-halogenated ICS that was developed in the early 1970s and is now one of the most widely used lung medicines worldwide. Inhaled budesonide's physiochemical and pharmacokinetic/pharmacodynamic properties allow it to reach a rapid and high airway efficacy due to its more balanced relationship between water solubility and lipophilicity. When absorbed from the airways and lung tissue, its moderate lipophilicity shortens systemic exposure, and its unique property of intracellular esterification acts like a sustained release mechanism within airway tissues, contributing to its airway selectivity and a low risk of adverse events. There is a large volume of clinical evidence supporting the efficacy and safety of budesonide, both alone and in combination with the fast- and long-acting β2-agonist formoterol, as maintenance therapy in patients with asthma and with COPD. The combination of budesonide/formoterol can also be used as an as-needed reliever with anti-inflammatory properties, with or without regular maintenance for asthma, a novel approach that is already approved by some country-specific regulatory authorities and currently recommended in the Global Initiative for Asthma (GINA) guidelines. Budesonide remains one of the most well-established and versatile of the inhaled anti-inflammatory drugs. This narrative review provides a clinical reappraisal of the benefit:risk profile of budesonide in the management of asthma and COPD.
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Affiliation(s)
- Donald P Tashkin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA, 90095-1690, USA.
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Ralph Brattsand
- Experimental Pharmacology, Budera Company, Kristinehamn, Sweden
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Balkissoon R. Journal Club-- COPD Exacerbations and Gastroesophageal Reflux Disease: Why Proton Pump Inhibitor Therapy is Not Enough. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2019; 6:374-379. [PMID: 31647860 PMCID: PMC7006696 DOI: 10.15326/jcopdf.6.4.2019.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Solidoro P, Patrucco F, Bagnasco D. Comparing a fixed combination of budesonide/formoterol with other inhaled corticosteroid plus long-acting beta-agonist combinations in patients with chronic obstructive pulmonary disease: a review. Expert Rev Respir Med 2019; 13:1087-1094. [DOI: 10.1080/17476348.2019.1665514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Paolo Solidoro
- Cardiovascular and Thoracic Department, SC Pneumologia U, Città della Salute e della Scienza (Molinette) University Hospital, Turin, Italy
| | - Filippo Patrucco
- Department of Translational Medicine, Pneumology Unit U, University of Piemonte Orientale, Vercelli, Italy
| | - Diego Bagnasco
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, University of Genoa, Genoa, Italy
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New therapeutic targets for the prevention of infectious acute exacerbations of COPD: role of epithelial adhesion molecules and inflammatory pathways. Clin Sci (Lond) 2019; 133:1663-1703. [PMID: 31346069 DOI: 10.1042/cs20181009] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
Chronic respiratory diseases are among the leading causes of mortality worldwide, with the major contributor, chronic obstructive pulmonary disease (COPD) accounting for approximately 3 million deaths annually. Frequent acute exacerbations (AEs) of COPD (AECOPD) drive clinical and functional decline in COPD and are associated with accelerated loss of lung function, increased mortality, decreased health-related quality of life and significant economic costs. Infections with a small subgroup of pathogens precipitate the majority of AEs and consequently constitute a significant comorbidity in COPD. However, current pharmacological interventions are ineffective in preventing infectious exacerbations and their treatment is compromised by the rapid development of antibiotic resistance. Thus, alternative preventative therapies need to be considered. Pathogen adherence to the pulmonary epithelium through host receptors is the prerequisite step for invasion and subsequent infection of surrounding structures. Thus, disruption of bacterial-host cell interactions with receptor antagonists or modulation of the ensuing inflammatory profile present attractive avenues for therapeutic development. This review explores key mediators of pathogen-host interactions that may offer new therapeutic targets with the potential to prevent viral/bacterial-mediated AECOPD. There are several conceptual and methodological hurdles hampering the development of new therapies that require further research and resolution.
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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: 2.8] [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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Lal C, Strange C. Evaluating fluticasone furoate + vilanterol for the treatment of chronic obstructive pulmonary disease (COPD). Expert Opin Pharmacother 2019; 20:1075-1085. [PMID: 30983423 DOI: 10.1080/14656566.2019.1603292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Inhaled corticosteroid/long-acting β-2 agonists (ICS/LABA) combination inhalers have been a lifeline for a generation of chronic obstructive pulmonary disease (COPD) and asthma patients. Fluticasone furoate and Vilanterol (FF/VI) as a once-daily ICS/LABA combination have an extensive clinical trial and real-world data to support its use in COPD patients. Areas covered: The authors provide pharmacological profiles of fluticasone furoate, vilanterol and the FF/VI fixed dose combination. Salient clinical trials evaluating efficacy and safety of the FF/VI combination, and studies demonstrating the impact on COPD exacerbation risk and mortality are also discussed. Expert opinion: ICS/LABA combinations provide bronchodilation and decrease the frequency of COPD exacerbations. Individualizing treatment of each COPD patient based on unique phenotypes will maximize chances of therapeutic responsiveness. Asthma-COPD overlap (ACO), patients with sputum and/or blood eosinophilia, patients with a brisk bronchodilator response, and patients with frequent exacerbations are more likely to show a therapeutic response to ICS than populations who have none of these features. FF/VI will likely remain a popular ICS/LBA combination to treat COPD, as a once-daily inhaled therapy delivered via the Ellipta device popular with COPD patients, with extensive clinical trial and real-world data to support its use.
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Affiliation(s)
- Chitra Lal
- a Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
| | - Charlie Strange
- a Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
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Radivojev S, Zellnitz S, Paudel A, Fröhlich E. Searching for physiologically relevant in vitro dissolution techniques for orally inhaled drugs. Int J Pharm 2019; 556:45-56. [DOI: 10.1016/j.ijpharm.2018.11.072] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/22/2018] [Accepted: 11/22/2018] [Indexed: 02/05/2023]
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Vanfleteren L, Fabbri LM, Papi A, Petruzzelli S, Celli B. Triple therapy (ICS/LABA/LAMA) in COPD: time for a reappraisal. Int J Chron Obstruct Pulmon Dis 2018; 13:3971-3981. [PMID: 30587953 PMCID: PMC6296179 DOI: 10.2147/copd.s185975] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Recently, two "fixed triple" single-inhaler combinations of an inhaled corticosteroid (ICS), a long-acting β2-agonist (LABA), and a long-acting muscarinic antagonist (LAMA) have become available for patients with COPD. This review presents the clinical evidence that led to the approval of these triple therapies, discusses the role of ICS in patients with COPD, and presents data on the relative efficacy of "fixed triple" (ICS/LAMA/LABA) therapy vs LAMA, ICS/LABA, and LAMA/LABA combinations, and summarizes studies in which ICS/LABAs were combined with LAMAs to form "open triple" combinations. Of the five main fixed triple studies completed so far, three evaluated the efficacy and safety of an extrafine formulation of beclometasone dipropionate, formoterol fumarate, and glycopyrronium; the other two studies evaluated fluticasone furoate, vilanterol, and umeclidinium. Overall, compared to LAMA, ICS/LABA, or LAMA/LABA, triple therapy decreased the risk of exacerbations and improved lung function and health status, with a favorable benefit-to-harm ratio. Furthermore, triple therapy showed a promising signal in terms of improved survival. The evidence suggests that triple therapy is the most effective treatment in moderate/severe symptomatic patients with COPD at risk of exacerbations, with marginal if any risk of side effects including pneumonia. Ongoing studies are examining the role of triple therapy in less severe symptomatic patients with COPD and asthma-COPD overlap.
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Affiliation(s)
- Lowie Vanfleteren
- COPD Center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden, .,CIRO, Horn, the Netherlands, .,Department of Respiratory Medicine, Maastricht University Medical Hospital, Maastricht, the Netherlands,
| | - Leonardo M Fabbri
- COPD Center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden, .,Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Bartolome Celli
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Tashkin DP, Miravitlles M, Celli BR, Metzdorf N, Mueller A, Halpin DMG, Anzueto A. Concomitant inhaled corticosteroid use and the risk of pneumonia in COPD: a matched-subgroup post hoc analysis of the UPLIFT® trial. Respir Res 2018; 19:196. [PMID: 30290801 PMCID: PMC6173940 DOI: 10.1186/s12931-018-0874-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/27/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Use of inhaled corticosteroids (ICS) increases the risk of pneumonia in chronic obstructive pulmonary disease (COPD), but the magnitude of risk with different ICS remains unclear. METHODS A post hoc analysis of the 4-year UPLIFT® trial to assess whether pneumonia risk differed by type of ICS (fluticasone propionate [FP], other ICS, or no ICS) in permanent users (defined by use until end of study) or in users at baseline (sensitivity analysis). RESULTS For the permanent-users analysis, 825 patients receiving FP throughout the trial, 825 patients receiving other ICS and 825 patients not receiving ICS were matched on relevant baseline features 1:1:1. A significantly greater risk of pneumonia was observed for FP versus no ICS: the hazard ratio (HR) for risk of pneumonia was 1.33 (95% confidence interval [CI] 1.00, 1.75; p = 0.046) and the rate ratio (RR) was 1.58 (95% CI 1.05, 2.37; p = 0.028). A greater risk was also found for FP versus other ICS: HR 1.28 (95% CI 0.97, 1.68; p = 0.078) and RR 1.48 (95% CI 1.00, 2.19; p = 0.049). A higher proportion of patients on FP were hospitalized with pneumonia (7.9%) versus other ICS (6.7%) or no ICS (5.9%). Whilst other ICS use was associated with the highest number of fatal pneumonia events, the total number of fatal pneumonia incidents was low. A similar pattern was observed in the sensitivity analyses, which included 4002 patients on different treatments at baseline (FP, other ICS, and no ICS) and considered potential switches during the study. CONCLUSION The results support existing evidence of an increased pneumonia risk with FP use compared with other ICS and no ICS use in patients with COPD. Healthcare professionals should evaluate the risk-benefit ratio of using ICS when making treatment decisions with their patients. TRIAL REGISTRATION Post hoc analysis of UPLIFT®. ClinicalTrials.gov number: NCT00144339 . Retrospectively registered September 2, 2005.
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Affiliation(s)
- Donald P. Tashkin
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095-1690 USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | - Norbert Metzdorf
- TA Respiratory/Biosimilars, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Achim Mueller
- Biostatistics and Data Sciences Europe, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | | | - Antonio Anzueto
- Pulmonary/Critical Care, University of Texas, and South Texas Veterans Health Care System, San Antonio, TX USA
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Lipworth B, Kuo CR, Jabbal S. Current appraisal of single inhaler triple therapy in COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:3003-3009. [PMID: 30319248 PMCID: PMC6167973 DOI: 10.2147/copd.s177333] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
A single inhaler containing inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA) is a more convenient way of delivering triple therapy in patients with COPD. Single triple therapy has been shown to be superior at reducing exacerbations and improving quality of life compared to LABA/LAMA, especially in patients with a prior history of frequent exacerbations and blood eosinophilia, who have ICS responsive disease. The corollary is that patients with infrequent exacerbations who are noneosinophilic may be safely de-escalated from triple therapy to LABA/LAMA without loss of control. Pointedly, there is a substantially increased risk of pneumonia associated with the triple therapy containing fluticasone furoate but not beclometasone dipropionate or budesonide. Since triple therapy is also better than ICS/LABA at reducing exacerbations and improving lung function, symptoms, and quality of life, this brings into question the rationale for using ICS/LABA. Hence, we propose a simplified pragmatic decision process based on symptoms, prior to exacerbation history, and blood eosinophils to select which patients should be given a single triple inhaler or LABA/LAMA. Differences in patient preference of inhaler device, formulations and drugs will also determine which triple inhaler prescribers elect to use.
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Affiliation(s)
- Brian Lipworth
- Division of Molecular & Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK,
| | - Chris RuiWen Kuo
- Division of Molecular & Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK,
| | - Sunny Jabbal
- Division of Molecular & Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK,
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Belchamber KB, Thomas CM, Dunne AE, Barnes PJ, Donnelly LE. Comparison of fluticasone propionate and budesonide on COPD macrophage and neutrophil function. Int J Chron Obstruct Pulmon Dis 2018; 13:2883-2897. [PMID: 30271135 PMCID: PMC6147211 DOI: 10.2147/copd.s169337] [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: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Kylie Br Belchamber
- Airway Disease Section, National Heart and Lung Institute, Dovehouse Street, Imperial College London, London, UK,
| | - Catherine Mr Thomas
- Airway Disease Section, National Heart and Lung Institute, Dovehouse Street, Imperial College London, London, UK,
| | - Amy E Dunne
- Airway Disease Section, National Heart and Lung Institute, Dovehouse Street, Imperial College London, London, UK,
| | - Peter J Barnes
- Airway Disease Section, National Heart and Lung Institute, Dovehouse Street, Imperial College London, London, UK,
| | - Louise E Donnelly
- Airway Disease Section, National Heart and Lung Institute, Dovehouse Street, Imperial College London, London, UK,
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Neder JA, Rocha A, Alencar MCN, Arbex F, Berton DC, Oliveira MF, Sperandio PA, Nery LE, O'Donnell DE. Current challenges in managing comorbid heart failure and COPD. Expert Rev Cardiovasc Ther 2018; 16:653-673. [PMID: 30099925 DOI: 10.1080/14779072.2018.1510319] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Heart failure (HF) with reduced ejection fraction and chronic obstructive pulmonary disease (COPD) frequently coexist, particularly in the elderly. Given their rising prevalence and the contemporary trend to longer life expectancy, overlapping HF-COPD will become a major cause of morbidity and mortality in the next decade. Areas covered: Drawing on current clinical and physiological constructs, the consequences of negative cardiopulmonary interactions on the interpretation of pulmonary function and cardiopulmonary exercise tests in HF-COPD are discussed. Although those interactions may create challenges for the diagnosis and assessment of disease stability, they provide a valuable conceptual framework to rationalize HF-COPD treatment. The impact of COPD or HF on the pharmacological treatment of HF or COPD, respectively, is then comprehensively discussed. Authors finalize by outlining how the non-pharmacological treatment (i.e. rehabilitation and exercise reconditioning) can be tailored to the specific needs of patients with HF-COPD. Expert commentary: Randomized clinical trials testing the efficacy and safety of new medications for HF or COPD should include a sizeable fraction of patients with these coexistent pathologies. Multidisciplinary clinics involving cardiologists and respirologists trained in both diseases (with access to unified cardiorespiratory rehabilitation programs) are paramount to decrease the humanitarian and social burden of HF-COPD.
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Affiliation(s)
- J Alberto Neder
- a Laboratory of Clinical Exercise Physiology , Kingston Health Science Center & Queen's University , Kingston , Canada.,b Heart Failure-COPD Outpatients Service and Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Divisions of Respirology and Cardiology , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Alcides Rocha
- b Heart Failure-COPD Outpatients Service and Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Divisions of Respirology and Cardiology , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Maria Clara N Alencar
- b Heart Failure-COPD Outpatients Service and Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Divisions of Respirology and Cardiology , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Flavio Arbex
- b Heart Failure-COPD Outpatients Service and Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Divisions of Respirology and Cardiology , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Danilo C Berton
- c Federal University of Rio Grande do Sul , Porto Alegre , Brazil
| | - Mayron F Oliveira
- b Heart Failure-COPD Outpatients Service and Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Divisions of Respirology and Cardiology , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Priscila A Sperandio
- b Heart Failure-COPD Outpatients Service and Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Divisions of Respirology and Cardiology , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Luiz E Nery
- b Heart Failure-COPD Outpatients Service and Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Divisions of Respirology and Cardiology , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Denis E O'Donnell
- d Respiratory Investigation Unit , Queen's University & Kingston General Hospital , Kingston , Canada
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Tashkin DP, Strange C. Inhaled corticosteroids for chronic obstructive pulmonary disease: what is their role in therapy? Int J Chron Obstruct Pulmon Dis 2018; 13:2587-2601. [PMID: 30214177 PMCID: PMC6118265 DOI: 10.2147/copd.s172240] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Donald P Tashkin
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA,
| | - Charlie Strange
- Department of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
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Lopez-Campos JL, Carrasco Hernández L, Muñoz X, Bustamante V, Barreiro E. Current controversies in the stepping up and stepping down of inhaled therapies for COPD at the patient level. Respirology 2018; 23:818-827. [PMID: 29924458 DOI: 10.1111/resp.13341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 12/23/2022]
Abstract
The implementation of potential new step-up or step-down treatment recommendations in response to current guidelines is one of the main challenges currently faced in actual daily practice settings. In the present narrative review, we aim to discuss the relevance of these step-up and step-down proposals at the patient level in daily clinical practice. In particular, we aim to review the challenges associated with inhaled maintenance therapy for chronic obstructive pulmonary disease (COPD) in four clinical scenarios. First, we discuss the step up from single to double bronchodilation, including current controversies regarding the addition of a second bronchodilator versus initial treatment with two bronchodilators. Second, we discuss the step up from double bronchodilation to triple therapy while challenging current indications for inhaled steroid therapy and discussing triple therapy designs. Third, we discuss the step down from triple therapy to double bronchodilation while evaluating the effect of this downshift in risk categories on the patient according to the new classifications. Finally, we discuss the step down from double to single bronchodilation, with a special focus on safety. We believe this review will help to highlight the most relevant discussion points regarding the treatment of COPD in a manner that will stimulate and guide related clinical research.
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Affiliation(s)
- Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Laura Carrasco Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Xavier Muñoz
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Service, Department of Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Víctor Bustamante
- Servicio de Neumología, Hospital Universitario Basurto, Osakidetza, Departamento de Medicina, EHU-University of the Basque Country, Vizcaya, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department (CEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
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50
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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: 2.4] [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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