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Li J, Dell'Aniello S, Ernst P, Suissa S. Real-world comparative effectiveness of three single-inhaler dual bronchodilators for the treatment of COPD. Eur Respir J 2023; 62:2300538. [PMID: 37343975 DOI: 10.1183/13993003.00538-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Single-inhaler dual bronchodilators are now recommended as initial treatment of COPD for patients with multiple exacerbations or with moderate or severe dyspnoea. It is unclear whether there are differences in effectiveness among commonly used dual bronchodilators. METHODS We identified a cohort of COPD patients, aged ≥40 years, treated during 2017-2020, from the UK Clinical Practice Research Datalink, a real-world practice setting. Inhaled corticosteroid-naïve patients initiating vilanterol-umeclidinium (VIL-UME) were compared with those initiating olodaterol-tiotropium (OLO-TIO) or indacaterol-glycopyrronium (IND-GLY) dual bronchodilators primarily on the incidence of moderate and severe COPD exacerbation over 1 year, and corresponding hazard ratios (HRs), after adjustment by propensity score weighting. RESULTS The cohort included 15 224 initiators of VIL-UME, 5536 initiators of OLO-TIO and 5059 initiators of IND-GLY. The HR of a moderate or severe exacerbation with VIL-UME was 0.91 (95% CI 0.85-0.97) compared with OLO-TIO and 0.96 (95% CI 0.89-1.03) compared with IND-GLY. The risk of severe exacerbation was not different for VIL-UME when compared with OLO-TIO (HR 1.04, 95% CI 0.86-1.26) and IND-GLY (HR 1.05, 95% CI 0.86-1.28). All-cause mortality was lower with VIL-UME compared with IND-GLY (HR 0.82, 95% CI 0.68-0.98), but not compared with OLO-TIO (HR 0.87, 95% CI 0.72-1.04). CONCLUSION In a real-world setting of COPD treatment, the three dual bronchodilator combinations were similarly effective on the risk of a severe exacerbation of COPD. However, the VIL-UME and IND-GLY combinations may confer slightly superior effectiveness than OLO-TIO on the risk of moderate or severe exacerbation. The potential lower mortality with VIL-UME warrants further investigation.
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Affiliation(s)
- Jiaying Li
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
- Department of Medicine, Jewish General Hospital, Montreal, QC, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, Montreal, QC, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
- Department of Medicine, Jewish General Hospital, Montreal, QC, Canada
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Kerwin EM, Jones PW, Bjermer LH, Maltais F, Boucot IH, Naya IP, Lipson DA, Compton C, Tombs L, Vogelmeier CF. How can the findings of the EMAX trial on long-acting bronchodilation in chronic obstructive pulmonary disease be applied in the primary care setting? Chron Respir Dis 2023; 20:14799731231202257. [PMID: 37800633 PMCID: PMC10903204 DOI: 10.1177/14799731231202257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 08/21/2023] [Indexed: 10/07/2023] Open
Abstract
This review addresses outstanding questions regarding initial pharmacological management of chronic obstructive pulmonary disease (COPD). Optimizing initial treatment improves clinical outcomes in symptomatic patients, including those with low exacerbation risk. Long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) dual therapy improves lung function versus LAMA or LABA monotherapy, although other treatment benefits have been less consistently observed. The benefits of dual bronchodilation in symptomatic patients with COPD at low exacerbation risk, and its duration of efficacy and cost effectiveness in this population, are not yet fully established. Questions remain on the impact of baseline symptom severity, prior treatment, degree of reversibility to bronchodilators, and smoking status on responses to dual bronchodilator treatment. Using evidence from EMAX (NCT03034915), a 6-month trial comparing the LAMA/LABA combination umeclidinium/vilanterol with umeclidinium and salmeterol monotherapy in symptomatic patients with COPD at low exacerbation risk who were inhaled corticosteroid-naïve, we describe how these findings can be applied in primary care.
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Affiliation(s)
- Edward M Kerwin
- Clinical Trials Department, Altitude Clinical Consulting and Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | - Leif H Bjermer
- Department of Clinical Sciences, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - François Maltais
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | | | | | - David A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Stockley Park West, Uxbridge, UK
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
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Miravitlles M, Matsunaga K, Dreher M. Stepwise management of COPD: What is next after bronchodilation? Ther Adv Respir Dis 2023; 17:17534666231208630. [PMID: 37936381 PMCID: PMC10631322 DOI: 10.1177/17534666231208630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, University Hospital Vall d′Hebron/Vall d’Hebron Research Institute (VHIR, Vall d’Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias [CIBERES]), P. Vall d’Hebron 119–129, Barcelona 08035, Spain
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
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Miravitlles M, Kawayama T, Dreher M. LABA/LAMA as First-Line Therapy for COPD: A Summary of the Evidence and Guideline Recommendations. J Clin Med 2022; 11:jcm11226623. [PMID: 36431099 PMCID: PMC9692772 DOI: 10.3390/jcm11226623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/27/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022] Open
Abstract
Inhaled bronchodilators (alone or in combination) are the cornerstone of treatment for symptomatic patients with COPD, either as initial/first-line treatment or for second-line/treatment escalation in patients who experience persistent symptoms or exacerbations on monotherapy. The Global Initiative for Chronic Obstructive Lung Disease 2022 report recommends initial pharmacological treatment with a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA) as monotherapy for most patients, or dual bronchodilator therapy (LABA/LAMA) in patients with more severe symptoms, regardless of exacerbation history. The recommendations for LABA/LAMA are broader in the American Thoracic Society treatment guidelines, which strongly recommend LABA/LAMA combination therapy over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance. However, despite consistent guideline recommendations, real-world prescribing data indicate that LAMA and/or LABA without an inhaled corticosteroid are not the most widely prescribed therapies in COPD. This article reviews global and regional/national guideline recommendations for the use of LABA/LAMA in COPD, examines the evidence for the effectiveness and safety of LABA/LAMA versus other therapies and offers a practical guide for clinicians to help ensure appropriate use of LABA/LAMA therapy.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d′Hebron, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Correspondence: ; Tel.: +34-(93)-274-6157
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, 52074 Aachen, Germany
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Salvi S, Jain MK, Krishnamurthy S, Balki A, Kodgule R, Tandon M, Bhagat S, Panchal S, Khatri N, Wu W, Pendse A, Patil S, Barkate H. Comparative efficacy and safety of glycopyrronium/formoterol fixed-dose combination versus glycopyrronium monotherapy in patients with moderate-to-severe COPD. Lung India 2022; 39:517-524. [PMID: 36629230 PMCID: PMC9746267 DOI: 10.4103/lungindia.lungindia_136_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 08/04/2022] [Indexed: 01/12/2023] Open
Abstract
Background The safety and efficacy of fixed-dose combination (FDC) of glycopyrronium bromide 12.5 μg/formoterol fumarate 12 μg (GB/FF) twice daily as dry powder inhalers (DPIs) compared to glycopyrronium 50 μg monotherapy (GLY) once daily as DPI in subjects with moderate-to-severe chronic obstructive pulmonary disease (COPD) were evaluated. Methods This was a phase-3, randomized, double-blind, active-controlled, parallel-group, superiority study conducted in India. COPD patients aged ≥40 to ≤65 years, current or ex-smokers with FEV1/FVC <0.70, using ICS, LAMA, or LABA for ≥1 month were included. Subjects were randomized (1:1) to GB/FF or GLY for 12 weeks. The primary efficacy endpoint was the change from baseline in peak FEV1 at the end of 12 weeks. The study is registered with the Clinical Trials Registry of India (CTRI/2017/02/007814). Results Between March 2017 and July 2018, 331 patients were enrolled and randomized into GB/FF FDC (165 patients) and GLY monotherapy (166 patients) groups. At week 12, the difference in change from baseline in the peak FEV1 for GB/FF DPI versus GLY was 0.115 L (SE = 0.02; 95% CI = 0.061, 0.170; P < 0.0001). Trough FEV1 increased significantly in the GB/FF group compared to the GLY group with a treatment difference of 0.078 L (SE = 0.02; 95% CI = 0.015, 0.14; P = 0.01). There were no significant differences in adverse events between the groups. Conclusion FDC of GB/FF (12.5/12 μg twice daily) as a DPI provides superior bronchodilation and lung function improvement over GLY (50 μg once daily) monotherapy. It is safe and well tolerated in symptomatic COPD patients.
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Affiliation(s)
- Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, Maharashtra, India
| | - Manish K. Jain
- Department of Respiratory, Maharaja Agrasen Superspeciality Hospital, Jaipur, Rajasthan, India
| | - Srikanth Krishnamurthy
- Department of Pulmonary and Respiratory Medicine, Sri Bala Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
| | - Akash Balki
- Shree Hospital and Critical Care, Nagpur, Maharashtra, India
| | - Rahul Kodgule
- Clinical Development, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Monika Tandon
- Clinical Development, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Sagar Bhagat
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Sagar Panchal
- Ex-Employee, Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Nishtha Khatri
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Wen Wu
- Clinical Operations, Glenmark Pharmaceuticals Ltd., Waterford, UK
| | - Amol Pendse
- Clinical Operations, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Saiprasad Patil
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Hanmant Barkate
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
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Kim DW, Weon KY. Pharmaceutical application and development of fixed-dose combination: dosage form review. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2021. [DOI: 10.1007/s40005-021-00543-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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