Inhaled Corticosteroids in COPD: Trying to Make a Long Story Short

Use of thiols and implications for the use of inhaled corticosteroids in the presence of oxidative stress in COPD

BACKGROUND

Oxidative stress and persistent airway inflammation are thought to be important contributors to the development of chronic obstructive pulmonary disease (COPD). This review summarizes the evidence for targeting oxidative stress and inflammation in patients with COPD with mucolytic/antioxidant thiols and inhaled corticosteroids (ICS), either alone or in combination.

MAIN BODY

Oxidative stress is increased in COPD, particularly during acute exacerbations. It can be triggered by oxidant air pollutants and cigarette smoke and/or by endogenous reactive oxygen species (ROS) released from mitochondria and activated inflammatory, immune and epithelial cells in the airways, together with a reduction in endogenous antioxidants such as glutathione (GSH). Oxidative stress also drives chronic inflammation and disease progression in the airways by activating intracellular signalling pathways and the release of further inflammatory mediators. ICS are anti-inflammatory agents currently recommended for use with long-acting bronchodilators to prevent exacerbations in patients with moderate-to-severe COPD, especially those with eosinophilic airway inflammation. However, corticosteroids can also increase oxidative stress, which may in turn reduce corticosteroid sensitivity in patients by several mechanisms. Thiol-based agents such as erdosteine, N-acetyl L-cysteine (NAC) and S-carboxymethylcysteine (S-CMC) are mucolytic agents that also act as antioxidants. These agents may reduce oxidative stress directly through the free sulfhydryl groups, serving as a source of reducing equivalents and indirectly though intracellular GSH replenishment. Few studies have compared the effects of corticosteroids and thiol agents on oxidative stress, but there is some evidence for greater antioxidant effects when they are administered together. The current Global Initiative for Chronic Obstructive Lung Disease (GOLD) report supports treatment with antioxidants (erdosteine, NAC, S-CMC) in addition to standard-of-care therapy as they have been demonstrated to reduce COPD exacerbations. However, such studies have demonstrated that NAC and S-CMC reduced the exacerbation risk only in patients not treated with ICS, whereas erdosteine reduced COPD exacerbations irrespective of concomitant ICS use suggesting that erdosteine has additional pharmacological actions to ICS.

CONCLUSIONS

Further clinical trials of antioxidant agents with and without ICS are needed to better understand the place of thiol-based drugs in the treatment of patients with COPD.

A Prediction Scoring Model for the Effect of Withdrawal or Addition of Inhaled Corticosteroids in Patients with Chronic Obstructive Pulmonary Disease

Purpose

The aims of this study were to develop a scoring model that predicts the effects of withdrawing inhaled corticosteroids (ICSs) from triple therapy and to examine its adaptability when applied to assess the effect of adding ICSs to dual bronchodilators patients with chronic obstructive pulmonary disease (COPD).

Patients and Methods

A scoring model was developed using the IMPACT study dataset, consisting of 2389 COPD patients treated with triple therapy before enrollment (ICS withdrawal dataset). The developed model consisted of COPD duration, Acute exacerbation history, Sex, Pulmonary function tests, blood Eosinophil count, and Race (CASPER) and was used to predict composite events of moderate-to-severe exacerbation, all-cause mortality, and pneumonia. Treatment heterogeneity was assessed using Cox interaction analyses. The CASPER model was applied to 540 COPD patients treated with dual bronchodilator before enrollment (ICS addition dataset). Validity was assessed using Harrell's C-index, time-dependent receiver operating characteristic curves, and calibration plots.

Results

The cumulative incidence of the composite event was 60.1% over 12 months in the ICS withdrawal dataset. Cox interaction analyses revealed that ICS was different according to race and blood eosinophil counts. The hazard ratios (HRs) for dual bronchodilator compared with triple therapy were 1.318 (95% confidence interval (CI)=1.170-1.485; P-value <0.001) in whites and 0.922 (95% CI = 0.712-1.195; P-value=0.541) in other races. The treatment effect was different in the eosinophil count ≥0.3 group (HR = 1.586; 95% CI = 1.274-1.975) and in the eosinophil count = 0.1-0.3 group (HR = 1.211; 95% CI = 1.041-1.408), but it was same in the eosinophil count <0.1 (HR = 1.009; P-value=0.940). The CASPER model performed well with good discrimination and calibration, which were superior to the prediction based on exacerbation history and blood eosinophil count.

Conclusion

The presented CASPER model might be able to predict and compare the risk of composite events when dual bronchodilator or triple therapy is administered to COPD patients.

Relationship Between Blood Eosinophils and Systemic Corticosteroid Therapy in COPD Exacerbation

Purpose

To assess the relationship between the duration of systemic corticosteroid therapy and blood eosinophil counts in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

Patients and Methods

This study included 292 patients with acute COPD exacerbations treated with daily intravenous injections of 40 mg/day methylprednisolone at the Department of Respiratory Medicine, Anhui No.2 Provincial People's Hospital, Hefei, China. The study subjects were divided into two groups - (1) a low-dose group (n = 136) that included patients treated with methylprednisolone for less than or equal to 5 days and (2) a high-dose group (n = 156) that included patients treated with methylprednisolone for more than 5 days. The blood eosinophil counts were analyzed for both the patient groups, and an optimal cut-off value was calculated to distinguish between the two groups. The study endpoints were readmission or deaths within 30 days or 180 days and re-infections within 90 days after hospital discharge.

Results

The mean blood eosinophil counts in the low- and high-dose groups were 0.15 × 109/L (0.11-0.23 × 109/L) and 0.08 × 109/L (0.04-0.12 × 109/L), respectively (P < 0.01). Receiver operating characteristic (ROC) curve analysis showed that the cut-off value for the blood eosinophils to distinguish the two patient groups was 0.115 × 109/L with a sensitivity and specificity of 72.8% and 72.4%, respectively. The number of readmissions between the two groups at 30 days and 180 days after hospital discharge did not show any significant differences (P = 0.292, P = 0.398). The follow-up data showed significantly higher rate of re-infections in the high-dose group (24/136) within 90 days after hospital discharge compared to the low-dose group (9/156) (P = 0.018).

Conclusion

In patients with acute exacerbations of COPD, blood eosinophil counts of ≥0.115 × 109/L were associated with effective response to corticosteroid therapy in ≤5 days.

An Add-On Treatment for Moderate COPD with Squill-Oxymel (a Traditional Formulation from Drimia maritima (L.) Stearn): A Pilot Randomized Triple-Blinded Placebo-Controlled Clinical Trial

Background. In traditional Persian medicine, Drimia maritima, with the popular name Squill, has been used to alleviate phlegm dyspnea. Squill has also been shown to have anti-inflammatory and anticholinergic properties. The goal of this research was to see how effective and safe Squill-Oxymel was in treating COPD patients. Method. Forty-two COPD patients were examined for eight weeks in two groups. Patients underwent a 6-minute walk test to assess the treatment’s effectiveness at the beginning and conclusion of the intervention. We utilized St. George’s Respiratory Questionnaire (SGRQ) to evaluate the subjective symptoms of patients in order to measure their quality of life. Results. Patients who received Squill-Oxymel showed a statistically significant increase in 6MWT distance ( $P=0.011$ ). The mean O2 saturation at the end of the 6MWT before the intervention was significantly greater in the placebo group. ( $P=0.008$ ). In terms of questionnaire variables, there was a significant difference between placebo and Squill-Oxymel groups in the mean presymptom score ( $P=0.009$ ) and the mean post-symptom score ( $P=0.004$ ). Conclusions. The findings of this research provide preliminary evidence for the effectiveness and safety of Squill-Oxymel as an add-on therapy in individuals with mild COPD.

Advances in inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease: what is their value today?

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.

Experience of using a triple fixed combination in the treatment of patients with chronic obstructive pulmonary disease

Aim. To evaluate the effectiveness of a fixed triple combination of vilanterol/umeclidinium bromide/fluticasone furoate in the treatment of chronic obstructive pulmonary disease (COPD) patients with frequent exacerbations. Materials and methods. The study included 46 patients with severe and extremely severe COPD (GOLD 34) with frequent exacerbations. All patients were divided into 2 groups. The 1st group included 22 COPD patients with a content of eosinophils in the peripheral blood of 300 cells/ml, the 2nd group included 24 COPD patients with no signs of eosinophilic inflammation in the peripheral blood. Group 1 patients were recommended therapy with a fixed triple combination of vilanterol/umeclidinium bromide/fluticasone furoate at a dose of 22/55/92 mcg 1 time per day, group 2 patients received vilanterol+umeclidinium bromide at a dose of 22/55 mcg 1 time per day. The duration of follow-up was 12 months. Results. After 12 months of treatment with a fixed triple combination of vilanterol/umeclidinium bromide/fluticasone furoate, a statistically significant decrease in peripheral blood eosinophilia was noted in patients with COPD with frequent exacerbations and peripheral blood eosinophilia (p=0.001), as well as a decrease in shortness of breath on the MMRs scale (p=0.001) and the frequency of exacerbations in patients with COPD with frequent exacerbations and eosinophilia (p=0.001). Conclusion. The use of a fixed combination of vilanterol/umeclidinium bromide/fluticasone furoate for 12 months allowed to reduce the impact of the disease, improve respiratory function and quality of life in COPD patients with eosinophilia.

Eosinophilic endotype of chronic obstructive pulmonary disease: similarities and differences from asthma

Approximately 25% to 40% of patients with chronic obstructive pulmonary disease (COPD) have the eosinophilic endotype. It is important to identify this group accurately because they are more symptomatic and are at increased risk for exacerbations and accelerated decline in forced expiratory volume in the 1st second. Importantly, this endotype is a marker of treat ment responsiveness to inhaled corticosteroid (ICS), resulting in decreased mortality risk. In this review, we highlight differences in the biology of eosinophils in COPD compared to asthma and the different definitions of the COPD eosinophilic endotype based on sputum and blood eosinophil count (BEC) with the corresponding limitations. Although BEC is useful as a biomarker for eosinophilic COPD endotype, optimal BEC cut-offs can be combined with clinical characteristics to improve its sensitivity and specificity. A targeted approach comprising airway eosinophilia and appropriate clinical and physiological features may improve identification of subgroups of patients who would benefit from biologic therapy or early use of ICS for disease modification.

Multifaceted Beneficial Effects of Erdosteine: More than a Mucolytic Agent

Erdosteine is a drug approved for the treatment of acute and chronic pulmonary diseases, originally developed as a mucolytic agent. It belongs to the thiol-based family of drugs that are known to also possess potentially important antioxidant and anti-inflammatory properties, and exhibit antibacterial activity against a variety of medically important bacterial species. Erdosteine is a prodrug that is metabolized to the ring-opening compound metabolite M1 (MET 1), which has mucolytic properties. Experimental studies have documented that erdosteine prevents or reduces lung tissue damage induced by oxidative stress and, in particular, that Met 1 also regulates reactive oxygen species production. The RESTORE study, which has been the only trial that investigated the effects of a thiol-based drug in chronic obstructive pulmonary disease (COPD) frequent exacerbators, documented that erdosteine significantly reduces the risk of acute exacerbations of COPD (AECOPDs), shortens their course, and also decreases the risk of hospitalization from COPD. The preventive action of erdosteine on AECOPDs was not affected by the presence or absence of inhaled corticosteroids (ICSs) or blood eosinophil count. These findings clearly contrast with the Global Initiative for Chronic Obstructive Lung Disease strategy’s approach to use erdosteine only in those COPD patients not treated simultaneously with an ICS. Furthermore, they support the possibility of using erdosteine in a step-down approach that in COPD is characterized by the withdrawal of the ICS.

Molecular Mechanisms of Lipid Metabolism Disorders in Infectious Exacerbations of Chronic Obstructive Pulmonary Disease

Exacerbations largely determine the character of the progression and prognosis of chronic obstructive pulmonary disease (COPD). Exacerbations are connected with changes in the microbiological landscape in the bronchi due to a violation of their immune homeostasis. Many metabolic and immune processes involved in COPD progression are associated with bacterial colonization of the bronchi. The objective of this review is the analysis of the molecular mechanisms of lipid metabolism and immune response disorders in the lungs in COPD exacerbations. The complex role of lipid metabolism disorders in the pathogenesis of some infections is only beginning to be understood, however, there are already fewer and fewer doubts even now about its significance both in the pathogenesis of infectious exacerbations of COPD and in general in the progression of the disease. It is shown that the lipid rafts of the plasma membranes of cells are involved in many processes related to the detection of pathogens, signal transduction, the penetration of pathogens into the cell. Smoking disrupts the normally proceeded processes of lipid metabolism in the lungs, which is a part of the COPD pathogenesis.

Z-alpha1-antitrypsin polymers and small airways disease: a new paradigm in alfa-1 anti-trypsin deficiency-related COPD development?

The presence of Alpha1-Antitrypsin (AAT) polymers, known to promote a sustained pro-inflammatory activity, has been previously demonstrated in bronchial biopsies of subjects with Z-AAT deficiency (AATD) suggesting a possible role in the development of COPD through a small airway disease impairment. The study aimed to assess the presence of small airways dysfunction and the potential correlation with the presence of Z-AAT polymers obtained by Exhaled Breath Condensate (EBC) collection in PiZZ subjects, as compared with matched healthy PiMM subjects. We enrolled 19 asymptomatic, never smoker subjects: 9 PiZZ and 10 PiMM as controls, without obstructive ventilatory defect (i.e., normal FEV1/VC% ratio). All subjects underwent complete pulmonary function tests (PFT). EBC was collected in all subjects. ELISA test was applied to search for Z-AAT polymers. The PiZZ subjects showed normal lung volumes and DLCO values. However, in comparison with PiMM subjects, the single breath test N2 wash-out revealed significant differences regarding the phase III slope (1.45±0.35 N2/L vs. 0.96±0.40 N2/L) (p<0.02) in the PiZZ subjects, while the closing volume/vital capacity ratio (14.3±4.5 % vs. 11.3±6.3 %) was not significantly increased. The ELISA test detected the presence of Z-AAT polymers in 44% of PiZZ patients. Asymptomatic, never smoker PiZZ subjects with normal spirometry and lung diffusion capacity showed airways impairment when compared to PiMM subjects. Although Z-AAT polymers were found only in 44% of PiZZ subjects, these findings suggest the possibility that chronic bronchiolitis can develop as a result of the long-term pro-inflammatory activity of Z-AAT polymers in subjects with Z-related AATD.

Assessment and treatment of airflow obstruction in patients with chronic obstructive pulmonary disorder: a guide for the clinician

Introduction: Chronic obstructive pulmonary disorder (COPD) is a common cause of disability, morbidity and mortality worldwide. Early diagnosis and adequate treatment maintained over time are crucial to reducing these harmful consequences.Areas covered Persistent, not reversible and naturally progressive airflow obstruction is the functional hallmark of COPD. Therefore, in the presence of individual and environmental risk factors, with or without reported suggestive symptoms, simple spirometry must be performed enough quickly to objectify an obstructive ventilatory defect and assist physicians in making a diagnosis of COPD. Then, to cope with the heterogeneity of COPD patients, more specific functional tests and imaging techniques should be implemented to better define the underlying prevalent disease and its severity. That is necessary to decide whether to introduce ICS and establish the initial level of the treatment with just one or two bronchodilators, to control and freeze, when possible, the underlying pathological process.Expert opinion: The objective assessment of airflow obstruction is mandatory to make a diagnosis of COPD, but the prevalent disease sustaining the disorder should also be investigated to select a targeted therapy, because main determinants of airflow obstruction can be different in COPD patients and may differently respond to treatment.

Effect of chronic obstructive pulmonary disease combined with ventilator-associated pneumonia on patient outcomes: A systematic review and meta-analysis

The purpose of the present systematic review and meta-analysis was to uncover whether chronic obstructive pulmonary disease (COPD) as a co-morbidity influences outcomes of patients with ventilator-associated pneumonia (VAP) compared to VAP alone and whether the development of VAP in patients with COPD is associated with poor outcome in comparison to COPD alone. An electronic search of the PubMed, Embase, Scopus, BioMed Central, CENTRAL and Google scholar databases for all types of studies assessing the influence of COPD on outcomes of patients with VAP and vice versa was performed. A total of 7 studies were included. Of these, 3 studies assessed the impact of COPD on outcomes of patients with VAP. Meta-analysis indicated that the presence of COPD significantly increased the mortality of patients with VAP [risk ratio (RR): 1.37, 95% CI: 1.14-1.65, I²=3%, P=0.007]. The analysis failed to demonstrate any significant effect of COPD on the duration of mechanical ventilation in patients with VAP [mean difference (MD): 2.37, 95% CI: -5.77 to 10.50, I²=38%, P=0.57]. However, the duration of the intensive care unit (ICU) stay was significantly longer in patients with COPD and VAP as compared with that of patients with VAP without COPD (MD: 5.53, 95% CI: 0.73-10.33, I²=0%, P=0.02). A total of 4 studies assessed the impact of VAP on outcomes of patients with COPD. Meta-analysis indicated that the presence of VAP significantly increased mortality of patients with COPD (RR: 1.52, 95% CI: 1.08-2.12, I²=71%, P=0.02). Pooled analysis indicated that the presence of VAP in patients with COPD significantly increased the duration of mechanical ventilation (MD: 13.73, 95% CI: 7.86-19.61, I²=92%, P<0.00001) and the duration of the ICU stay as compared to patients with COPD but without VAP (MD: 17.36, 95% CI: 9.55-25.17, I²=90%, P<0.0001). To conclude, within the limitations of the study, the present results indicated that the combination of COPD and VAP significantly increased patient mortality and the duration of ICU stay. The development of VAP in patients with COPD also significantly increased the duration of mechanical ventilation. Further case-matched studies are required to assess the influence of the severity of COPD in combination with VAP on patient outcomes.