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Banzato R, Pinheiro-Menegasso NM, Novelli FPRS, Olivo CR, Taguchi L, de Oliveira Santos S, Fukuzaki S, Teodoro WPR, Lopes FDTQS, Tibério IFLC, de Toledo-Arruda AC, Prado MAM, Prado VF, Prado CM. Alpha-7 Nicotinic Receptor Agonist Protects Mice Against Pulmonary Emphysema Induced by Elastase. Inflammation 2024; 47:958-974. [PMID: 38227123 DOI: 10.1007/s10753-023-01953-9] [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: 10/23/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/17/2024]
Abstract
Pulmonary emphysema is a primary component of chronic obstructive pulmonary disease (COPD), a life-threatening disorder characterized by lung inflammation and restricted airflow, primarily resulting from the destruction of small airways and alveolar walls. Cumulative evidence suggests that nicotinic receptors, especially the α7 subtype (α7nAChR), is required for anti-inflammatory cholinergic responses. We postulated that the stimulation of α7nAChR could offer therapeutic benefits in the context of pulmonary emphysema. To investigate this, we assessed the potential protective effects of PNU-282987, a selective α7nAChR agonist, using an experimental emphysema model. Male mice (C57BL/6) were submitted to a nasal instillation of porcine pancreatic elastase (PPE) (50 µl, 0.667 IU) to induce emphysema. Treatment with PNU-282987 (2.0 mg/kg, ip) was performed pre and post-emphysema induction by measuring anti-inflammatory effects (inflammatory cells, cytokines) as well as anti-remodeling and anti-oxidant effects. Elastase-induced emphysema led to an increase in the number of α7nAChR-positive cells in the lungs. Notably, both groups treated with PNU-282987 (prior to and following emphysema induction) exhibited a significant decrease in the number of α7nAChR-positive cells. Furthermore, both groups treated with PNU-282987 demonstrated decreased levels of macrophages, IL-6, IL-1β, collagen, and elastic fiber deposition. Additionally, both groups exhibited reduced STAT3 phosphorylation and lower levels of SOCS3. Of particular note, in the post-treated group, PNU-282987 successfully attenuated alveolar enlargement, decreased IL-17 and TNF-α levels, and reduced the recruitment of polymorphonuclear cells to the lung parenchyma. Significantly, it is worth noting that MLA, an antagonist of α7nAChR, counteracted the protective effects of PNU-282987 in relation to certain crucial inflammatory parameters. In summary, these findings unequivocally demonstrate the protective abilities of α7nAChR against elastase-induced emphysema, strongly supporting α7nAChR as a pivotal therapeutic target for ameliorating pulmonary emphysema.
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Affiliation(s)
- Rosana Banzato
- Department of Internal Medicine, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Nathalia M Pinheiro-Menegasso
- Department of Biosciences, Instituto de Saúde e Sociedade, Universidade Federal de São Paulo, Rua Silva Jardim 136 sala 312, Santos, SP, 11015-020, Brazil
| | | | - Clarice R Olivo
- Department of Internal Medicine, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Laura Taguchi
- Department of Biosciences, Instituto de Saúde e Sociedade, Universidade Federal de São Paulo, Rua Silva Jardim 136 sala 312, Santos, SP, 11015-020, Brazil
| | - Stheffany de Oliveira Santos
- Department of Biosciences, Instituto de Saúde e Sociedade, Universidade Federal de São Paulo, Rua Silva Jardim 136 sala 312, Santos, SP, 11015-020, Brazil
| | - Silvia Fukuzaki
- Department of Internal Medicine, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Walcy Paganelli Rosolia Teodoro
- Rheumatology Division of the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, FMUSP, São Paulo, Brazil
| | - Fernanda D T Q S Lopes
- Department of Internal Medicine, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Iolanda F L C Tibério
- Department of Internal Medicine, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | | | - Marco Antônio M Prado
- Department of Physiology & Pharmacology, University of Western Ontario, London, Canada
- Department of Anatomy & Cell Biology, University of Western Ontario, London, Canada
| | - Vânia F Prado
- Department of Physiology & Pharmacology, University of Western Ontario, London, Canada
- Department of Anatomy & Cell Biology, University of Western Ontario, London, Canada
| | - Carla M Prado
- Department of Internal Medicine, School of Medicine, Universidade de São Paulo, São Paulo, Brazil.
- Department of Biosciences, Instituto de Saúde e Sociedade, Universidade Federal de São Paulo, Rua Silva Jardim 136 sala 312, Santos, SP, 11015-020, Brazil.
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Chen Z, Zha L, Hu B, Xu B, Zuo L, Yang J, Chu Z, Ma L, Hu F. Use of the Serum Level of Cholinesterase as a Prognostic Marker of Nonfatal Clinical Outcomes in Patients Hospitalized with Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Can Respir J 2024; 2024:6038771. [PMID: 38505803 PMCID: PMC10950411 DOI: 10.1155/2024/6038771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 11/27/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
Introduction Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) contributes to a poor prognosis. Reliable biomarkers to predict adverse outcomes during hospitalization are important. Aim To investigate the relationship between the serum cholinesterase (ChE) level and adverse clinical outcomes, including hypoxemia severity, hypercapnia, duration of hospital stay (DoHS), and noninvasive ventilation (NIV) requirement, in patients with AECOPD. Methods Patients hospitalized with AECOPD in the Wuhu Hospital of Traditional Chinese Medicine between January 2017 and December 2021 were included. Results A total of 429 patients were enrolled. The serum ChE level was significantly lower in patients with hypercapnia, who required NIV during hospitalization and who had a DoHS of >10 days, with an oxygenation index < 300. The ChE level was correlated negatively with the C-reactive protein level and neutrophil-to-lymphocyte ratio and correlated positively with the serum albumin level. Multivariate logistic regression analysis indicated that a serum ChE level of ≤4116 U/L (OR = 2.857, 95% CI = 1.46-5.58, p = 0.002) was associated significantly with NIV requirement. Conclusions The serum ChE level was correlated significantly with complicating severe hypoxemia, hypercapnia, prolonged DoHS, and the need for NIV in patients hospitalized with AECOPD. The serum ChE level is a clinically important risk-stratification biomarker in patients hospitalized with AECOPD.
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Affiliation(s)
- Zhixiang Chen
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
| | - Lei Zha
- Department of Respiratory Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu City, Anhui Province, China
| | - Bin Hu
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
| | - Bin Xu
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
| | - Lin Zuo
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
| | - Jun Yang
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
| | - Zhuhua Chu
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
| | - Lingling Ma
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
| | - Fangfang Hu
- Department of Respiratory and Critical Care Medicine, Wuhu Hospital of Traditional Chinese Medicine, 430 Jiuhua South Road, Wuhu, Anhui Province, China
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Bhatt SP, Agusti A, Bafadhel M, Christenson SA, Bon J, Donaldson GC, Sin DD, Wedzicha JA, Martinez FJ. Phenotypes, Etiotypes, and Endotypes of Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2023; 208:1026-1041. [PMID: 37560988 PMCID: PMC10867924 DOI: 10.1164/rccm.202209-1748so] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 08/04/2023] [Indexed: 08/11/2023] Open
Abstract
Chronic obstructive pulmonary disease is a major health problem with a high prevalence, a rising incidence, and substantial morbidity and mortality. Its course is punctuated by acute episodes of increased respiratory symptoms, termed exacerbations of chronic obstructive pulmonary disease (ECOPD). ECOPD are important events in the natural history of the disease, as they are associated with lung function decline and prolonged negative effects on quality of life. The present-day therapy for ECOPD with short courses of antibiotics and steroids and escalation of bronchodilators has resulted in only modest improvements in outcomes. Recent data indicate that ECOPD are heterogeneous, raising the need to identify distinct etioendophenotypes, incorporating traits of the acute event and of patients who experience recurrent events, to develop novel and targeted therapies. These characterizations can provide a complete clinical picture, the severity of which will dictate acute pharmacological treatment, and may also indicate whether a change in maintenance therapy is needed to reduce the risk of future exacerbations. In this review we discuss the latest knowledge of ECOPD types on the basis of clinical presentation, etiology, natural history, frequency, severity, and biomarkers in an attempt to characterize these events.
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Affiliation(s)
- Surya P. Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alvar Agusti
- Institut Respiratori (Clinic Barcelona), Càtedra Salut Respiratoria (Universitat de Barcelona), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS-Barcelona), Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), España
| | - Mona Bafadhel
- Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
| | - Stephanie A. Christenson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California
| | - Jessica Bon
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Gavin C. Donaldson
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Don D. Sin
- Centre for Heart Lung Innovation and
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- St. Paul’s Hospital, Vancouver, British Columbia, Canada; and
| | - Jadwiga A. Wedzicha
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Singh D, Litewka D, Páramo R, Rendon A, Sayiner A, Tanni SE, Acharya S, Aggarwal B, Ismaila AS, Sharma R, Daley-Yates P. DElaying Disease Progression In COPD with Early Initiation of Dual Bronchodilator or Triple Inhaled PharmacoTherapy (DEPICT): A Predictive Modelling Approach. Adv Ther 2023; 40:4282-4297. [PMID: 37382864 PMCID: PMC10499693 DOI: 10.1007/s12325-023-02583-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Clinical studies demonstrate an accelerated decline in lung function in patients with moderate chronic obstructive pulmonary disease (COPD) (Global Initiative for Chronic Obstructive Lung Disease [GOLD] grade 2) versus severe and very severe COPD (GOLD grades 3 and 4). This predictive modelling study assessed the impact of initiating pharmacotherapy earlier versus later on long-term disease progression in COPD. METHODS The modelling approach used data on decline in forced expiratory volume in 1 s (FEV1) extracted from published studies to develop a longitudinal non-parametric superposition model of lung function decline with progressive impact of exacerbations from 0 per year to 3 per year and no ongoing pharmacotherapy. The model simulated decline in FEV1 and annual exacerbation rates from age 40 to 75 years in COPD with initiation of long-acting anti-muscarinic antagonist (LAMA)/long-acting beta2-agonist (LABA) (umeclidinium (UMEC)/vilanterol (VI)) or triple (inhaled corticosteroid (ICS)/LAMA/LABA; fluticasone furoate (FF)/UMEC/VI) therapy at 40, 55 or 65 years of age. RESULTS Model-predicted decline in FEV1 showed that, compared with 'no ongoing' therapy, initiation of triple or LAMA/LABA therapy at age 40, 55 or 65 years preserved an additional 469.7 mL or 236.0 mL, 327.5 mL or 203.3 mL, or 213.5 mL or 137.5 mL of lung function, respectively, by the age of 75. The corresponding average annual exacerbation rates were reduced from 1.57 to 0.91, 1.06 or 1.23 with triple therapy or to 1.2, 1.26 and 1.4 with LAMA/LABA therapy when initiated at 40, 55 or 65 years of age, respectively. CONCLUSIONS This modelling study suggests that earlier initiation of LAMA/LABA or triple therapy may have positive benefits in slowing disease progression in patients with COPD. Greater benefits were demonstrated with early initiation therapy with triple versus LAMA/LABA.
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Affiliation(s)
- Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Diego Litewka
- Pulmonology Unit, Hospital General de Agudos Dr. J. A. Fernández, Buenos Aires, Argentina
| | | | - Adrian Rendon
- Universidad Autónoma de Nuevo León, Servicio de Neumología, CIPTIR, Monterrey, NL, México
| | - Abdullah Sayiner
- Department of Chest Diseases, Ege University Faculty of Medicine, İzmir, Turkey
| | - Suzana E Tanni
- Department of Botucatu Medical School, Universidade Estadual Paulista, São Paulo, Brazil
| | | | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Peter Daley-Yates
- Clinical Pharmacology and Experimental Medicine, GSK, Brentford, London, UK.
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Yii A, Xu X, Loh CH, Bahety P, Navarro Rojas AA, Milea D, Tee A. Year-to-year trajectories of hospital utilisation rates among patients with COPD: a real-world, single-centre, retrospective cohort study. BMJ Open 2023; 13:e072571. [PMID: 37657841 PMCID: PMC10476133 DOI: 10.1136/bmjopen-2023-072571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/09/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES The long-term clinical trajectory of chronic obstructive pulmonary disease (COPD) in terms of year-to-year hospital utilisation rates can be highly variable and is not well studied. We investigated year-to-year trends of hospitalisation or emergency department (ED) visits among patients with COPD over 3 years, identified distinct trajectories and examined associated predictive factors. DESIGN A retrospective cohort study. SETTING Data were extracted from the Changi General Hospital, Singapore COPD data warehouse. PARTICIPANTS Patients with COPD aged ≥40 years with 3 years of follow-up data. PRIMARY AND SECONDARY OUTCOME MEASURES The yearly rates of hospitalisations or ED visits, stratified by COPD-related or all-cause, were described. Group-based trajectory modelling was used to identify clinically distinct trajectories year-by-year. Baseline predictive factors associated with different trajectories were examined. RESULTS In total, 396 patients were analysed (median age 70 years; 87% male). Four trajectories were generated for year-to-year trends in COPD-related hospitalisations/ED visits (C1-C4: consistently frequent, consistently infrequent, improving and worsening); post-bronchodilator forced expiratory volume in 1 second (FEV1) was a significant predictor of trajectory, with worse lung function being the main factor associated with less favourable trajectories. For all-cause hospitalisations/ED visits, four trajectories were identified (A1-A4: infrequent and stable, frequent and stable, frequent and decreasing, frequent and increasing); significant differences in age (p=0.041), sex (p=0.016) and ethnicity (p=0.005) were found between trajectories. Higher overall comorbidity burden was a key determinant in less favourable trajectories of all-cause hospitalisations/ED visits. CONCLUSIONS Distinct trajectories were demonstrated for hospitalisations/ED visits related to COPD or all causes, with predictive associations between FEV1 and COPD trajectory and between comorbidities and all-cause trajectory. Trajectories carry nuanced prognostic information and may be useful for clinical risk stratification to identify high-risk individuals for preventative treatments.
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Affiliation(s)
- Anthony Yii
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Xiaomeng Xu
- Value Evidence and Outcomes, GSK, Greater China and Intercontinental, Singapore
| | - Chee Hong Loh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Priti Bahety
- Medical Affairs, GSK, Greater China and Intercontinental, Singapore
| | | | - Dominique Milea
- Value Evidence and Outcomes, GSK, Greater China and Intercontinental, Singapore
| | - Augustine Tee
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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Fahlevie F, Apriningsih H, Sutanto YS, Reviono R, Adhiputri A, Aphridasari J, Prasetyo W. Effects of secretome supplementation on interleukin-6, tumor necrosis factor-α, procalcitonin, and the length of stay in acute exacerbation COPD patients. NARRA J 2023; 3:e171. [PMID: 38450275 PMCID: PMC10916412 DOI: 10.52225/narra.v3i2.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/15/2023] [Indexed: 03/08/2024]
Abstract
Acute exacerbation chronic obstructive pulmonary disease (AECOPD) is associated with significant poor survival. Mesenchymal stem cells (MSC) therapy has been a promising treatment for COPD; therefore, it has the potential to be an additional therapy for AECOPD. Its potential is associated with its secretome since it has anti-inflammatory and immunomodulator activities. The aim of this study was to determine the effect of the secretome as an adjuvant therapy in reducing the levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), procalcitonin, and the length of stay in AECOPD patients. A clinical control trial study was conducted among 28 moderate and severe AECOPD patients who were hospitalized from January to February 2023. The control group (n=14) received standard therapy of AECOPD while the treatment group (n=14) received standard therapy plus secretome 1 ml twice daily for three days. The levels of IL-6, TNF-α, and procalcitonin were measured at admission and on the fourth day of treatment. The length of stay was calculated from the time the patient was admitted until the patient was discharged from hospital. The data were compared using a paired Student t-test, chi-squared test and Mann-Whitney test as appropriate. In the treatment group, the levels of IL-6, TNF-α and procalcitonin after the treatment reduced 13.09 pg/mL, 5.00 pg/mL and 751.26 pg/mL, respectively compared to pre-treatment. In contrast, the levels of IL-6, TNF-α and procalcitonin increased 48.56 pg/mL, 44.48 pg/mL and 346.96 pg/mL, respectively after four days of treatment. There was a significant reduction of IL-6, TNF-α and procalcitonin in treatment group compared to the control group with p=0.022, p=0.009 and p=0.001, respectively. However, there was no significant reduction of the length of stay (p=0.072). In conclusion, administration of secretome to AECOPD patients could reduce the levels of IL-6, TNF-α and procalcitonin.
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Affiliation(s)
- Fahlevie Fahlevie
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,Indonesia
- Department of Pulmonology and Respiratory Medicine, Dr. Moewardi General Hospital, Surakarta, Indonesia
| | - Hendrastutik Apriningsih
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,Indonesia
- Department of Pulmonology and Respiratory Medicine, Universitas Sebelas Maret Hospital, Surakarta, Indonesia
| | - Yusup S. Sutanto
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,Indonesia
- Department of Pulmonology and Respiratory Medicine, Dr. Moewardi General Hospital, Surakarta, Indonesia
| | - Reviono Reviono
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,Indonesia
- Department of Pulmonology and Respiratory Medicine, Universitas Sebelas Maret Hospital, Surakarta, Indonesia
| | - Artrien Adhiputri
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,Indonesia
- Department of Pulmonology and Respiratory Medicine, Dr. Moewardi General Hospital, Surakarta, Indonesia
| | - Jatu Aphridasari
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,Indonesia
- Department of Pulmonology and Respiratory Medicine, Dr. Moewardi General Hospital, Surakarta, Indonesia
| | - Windu Prasetyo
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,Indonesia
- Department of Pulmonology and Respiratory Medicine, Dr. Soehadi Prijonegoro General Hospital, Sragen, Indonesia
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ICS/Ultra LABA in the Treatment of Obstructive Airway Diseases: A Consensus of Indian Experts. Adv Respir Med 2022; 90:407-424. [DOI: 10.3390/arm90050051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/26/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022]
Abstract
Inhaled corticosteroid and ultra-long-acting beta-agonist (ICS/uLABA) combination is a recent advancement in the armamentarium against obstructive airways diseases (OADs). The combination of ICS/uLABA has several advantages, creating a favorable landscape for its utilization. Fluticasone furoate/vilanterol trifenatate (FF/Vi) is one such example of an ICS/uLABA. It offers several benefits from both drugs, such as a convenient once daily dosing schedule; high lipophilicity; high receptor affinity of fluticasone furoate along with high functional selectivity and a quick onset of action of vilanterol. However, the Global Initiative for Asthma (GINA) as well as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines do not clearly define the positioning of ICS/uLABA compared to conventional ICS/LABAs. There are a few areas of uncertainty especially around the appropriate reliever strategy with ICS/uLABA in Asthma. The current consensus was planned with a group of Indian pulmonology experts to provide more clarity on the potential use of FF/Vi in Asthma and COPD. The clinical statements highlighted in this consensus manuscript address crucial clinical questions revolving around the efficacy and safety of FF/Vi as compared to conventional ICS/LABAs and identify the ideal patient profile for its use. This consensus paper also sheds light upon the appropriate reliever to be used along with FF/Vi in Asthma and the utilization of FF/Vi-based triple therapy in OADs. Expert recommendations mentioned in this paper will serve as guidance to pulmonologists as well as consultant physicians who are involved in providing care to OAD patients and will help them weigh the various factors that need to be taken into account while prescribing ICS/uLABA combination.
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Pace WD, Brandt E, Carter VA, Chang KL, Edwards CL, Evans A, Fox C, Gaona G, Han MK, Kaplan AG, Kent R, Kocks JWH, Kruszyk M, Le Lievre CE, Li Voti T, Mahle C, Make B, Ratigan AR, Shaikh A, Skolnik N, Stanley B, Yawn BP, Price DB. COPD Population in US Primary Care: Data From the Optimum Patient Care DARTNet Research Database and the Advancing the Patient Experience in COPD Registry. Ann Fam Med 2022; 20:319-327. [PMID: 35879087 PMCID: PMC9328699 DOI: 10.1370/afm.2829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 12/13/2021] [Accepted: 01/06/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To describe demographic and clinical characteristics of chronic obstructive pulmonary disease patients managed in US primary care. METHODS This was an observational registry study using data from the Chronic Obstructive Pulmonary Disease (COPD) Optimum Patient Care DARTNet Research Database from which the Advancing the Patient Experience COPD registry is derived. Registry patients were aged ≥35 years at diagnosis. Electronic health record data were collected from both registries, supplemented with patient-reported information/outcomes from the Advancing the Patient Experience registry from 5 primary care groups in Texas, Ohio, Colorado, New York, and North Carolina (June 2019 through November 2020). RESULTS Of 17,192 patients included, 1,354 were also in the Advancing the Patient Experience registry. Patients were predominantly female (56%; 9,689/17,192), White (64%; 9,732/15,225), current/ex-smokers (80%; 13,784/17,192), and overweight/obese (69%; 11,628/16,849). The most commonly prescribed maintenance treatments were inhaled corticosteroid with a long-acting β2-agonist (30%) and inhaled corticosteroid with a long-acting muscarinic antagonist (27%). Although 3% (565/17,192) of patitents were untreated, 9% (1,587/17,192) were on short-acting bronchodilator monotherapy, and 4% (756/17,192) were on inhaled corticosteroid monotherapy. Despite treatment, 38% (6,579/17,192) of patients experienced 1 or more exacerbations in the last 12 months. These findings were mirrored in the Advancing Patient Experience registry with many patients reporting high or very high impact of disease on their health (43%; 580/1,322), a breathlessness score 2 or more (45%; 588/1,315), and 1 or more exacerbation in the last 12 months (50%; 646/1,294). CONCLUSIONS Our findings highlight the high exacerbation, symptom, and treatment burdens experienced by COPD patients managed in US primary care, and the need for more real-life effectiveness trials to support decision making at the primary care level.
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Affiliation(s)
- Wilson D Pace
- DARTNet Institute, Aurora, Colorado.,University of Colorado Denver, Denver, Colorado
| | | | | | - Ku-Lang Chang
- University of Florida College of Medicine, Gainesville, Florida
| | | | | | - Chester Fox
- DARTNet Institute, Aurora, Colorado.,University at Buffalo, Buffalo, New York
| | | | | | - Alan G Kaplan
- Observational & Pragmatic Research Institute, Singapore.,Family Physician Airways Group of Canada, Stouffville, Ontario, Canada.,University of Toronto, Toronto, Canada
| | | | - Janwillem W H Kocks
- Observational & Pragmatic Research Institute, Singapore.,General Practitioners Research Institute, Groningen, The Netherlands
| | | | | | | | - Cathy Mahle
- Boehringer Ingelheim, Ridgefield, Connecticut
| | - Barry Make
- Department of Medicine, National Jewish Health, Denver, Colorado
| | | | - Asif Shaikh
- Boehringer Ingelheim, Ridgefield, Connecticut
| | - Neil Skolnik
- Thomas Jefferson University, Woodbury, New Jersey.,Abington Jefferson Health, Jenkintown, Pennsylvania
| | - Brooklyn Stanley
- Optimum Patient Care, Cambridge, United Kingdom.,Observational & Pragmatic Research Institute, Singapore
| | - Barbara P Yawn
- University of Minnesota, Minneapolis, Minnesota.,COPD Foundation, Washington, DC
| | - David B Price
- Observational & Pragmatic Research Institute, Singapore; .,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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Rhodes K, Jenkins M, de Nigris E, Aurivillius M, Ouwens M. Relationship between risk, cumulative burden of exacerbations and mortality in patients with COPD: modelling analysis using data from the ETHOS study. BMC Med Res Methodol 2022; 22:150. [PMID: 35614467 PMCID: PMC9134588 DOI: 10.1186/s12874-022-01616-7] [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: 04/21/2021] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The major drivers of cost-effectiveness for chronic obstructive pulmonary disease (COPD) therapies are the occurrence of exacerbations and deaths. Exacerbations, including acute and long-term events, can cause worsening of COPD and lead to an increased risk of further exacerbations, and ultimately may elevate the risk of death. In contrast to this, health economic models are based on COPD severity progression. In this post hoc analysis of the ETHOS study, we focus on the progression of COPD due to exacerbations and deaths. METHODS We fitted semi-parametric and fully parametric multi-state Markov models with the following five progressive states: State 1, no exacerbation; State 2, 1 moderate exacerbation; State 3, ≥ 2 moderate exacerbations; State 4, ≥ 1 severe exacerbations; State 5, death. The models only allowed a patient to transition to a worsened health state, and transitions did not necessarily have to be to the next adjacent state. We used the multi-state models to analyse data from ETHOS, a phase III, 52-week study assessing the efficacy and safety of triple therapy with budesonide/glycopyrronium/formoterol fumarate dihydrate in moderate-to-very severe COPD. RESULTS The Weibull multi-state Markov model showed good fit of the data. In line with clinical evidence, we found a higher mortality risk after a severe exacerbation (11.4-fold relative ratio increase [95% CI, 7.7-17.0], 6.4-fold increase [95% CI, 3.8-10.8] and 5.4-fold increase [95% CI, 2.9-10.3] relative to no exacerbations, 1 moderate exacerbation or ≥ 2 moderate exacerbations, respectively). One moderate exacerbation increased mortality risk 1.8-fold (95% CI, 1.1-2.9) vs no exacerbations. We also found a higher risk of severe exacerbation and mortality following ≥ 2 moderate exacerbations. CONCLUSION Multi-state modelling of patients with COPD in ETHOS found an acute and chronic effect of severe exacerbations on mortality risk. Risk was also increased after a moderate exacerbation. Clinical management with effective pharmacotherapies should be optimised to avoid even moderate exacerbations. Modelling with exacerbations could be an alternative to current COPD models focused on disease progression. TRIAL REGISTRATION NCT02465567.
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Affiliation(s)
- Kirsty Rhodes
- Medical & Payer Evidence Statistics, Real-World Science and Digital, BioPharmaceuticals Medical Evidence, AstraZeneca, Academy House, Hills Road, Cambridge, CB2 8PA, UK.
| | | | | | | | - Mario Ouwens
- Medical & Payer Evidence Statistics, Real-World Science and Digital, BioPharmaceuticals Medical Evidence, AstraZeneca, Gothenburg, Sweden
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10
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Alves L, Pullen R, Hurst JR, Miravitlles M, Carter V, Chen R, Couper A, Dransfield M, Evans A, Hardjojo A, Jones D, Jones R, Kerr M, Kostikas K, Marshall J, Martinez F, van Melle M, Murray R, Muro S, Nordon C, Pollack M, Price C, Sharma A, Singh D, Winders T, Price DB. CONQUEST: A Quality Improvement Program for Defining and Optimizing Standards of Care for Modifiable High-Risk COPD Patients. Patient Relat Outcome Meas 2022. [DOI: 10.2147/prom.s296506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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11
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Kotlyarov S, Kotlyarova A. Anti-Inflammatory Function of Fatty Acids and Involvement of Their Metabolites in the Resolution of Inflammation in Chronic Obstructive Pulmonary Disease. Int J Mol Sci 2021; 22:ijms222312803. [PMID: 34884621 PMCID: PMC8657960 DOI: 10.3390/ijms222312803] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 12/13/2022] Open
Abstract
Lipid metabolism plays an important role in many lung functions. Disorders of lipid metabolism are part of the pathogenesis of chronic obstructive pulmonary disease (COPD). Lipids are involved in numerous cross-linkages with inflammation. Recent studies strongly support the involvement of fatty acids as participants in inflammation. They are involved in the initiation and resolution of inflammation, including acting as a substrate for the formation of lipid mediators of inflammation resolution. Specialized pro-inflammatory mediators (SPMs) belonging to the classes of lipoxins, resolvins, maresins, and protectins, which are formed enzymatically from unsaturated fatty acids, are now described. Disorders of their production and function are part of the pathogenesis of COPD. SPMs are currently the subject of active research in order to find new drugs. Short-chain fatty acids are another important participant in metabolic and immune processes, and their role in the pathogenesis of COPD is of great clinical interest.
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Affiliation(s)
- Stanislav Kotlyarov
- Department of Nursing, Ryazan State Medical University, 390026 Ryazan, Russia
- Correspondence:
| | - Anna Kotlyarova
- Department of Pharmacology and Pharmacy, Ryazan State Medical University, 390026 Ryazan, Russia;
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12
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Cabrera C, Quélen C, Ouwens M, Hedman K, Rigney U, Quint JK. Evaluating a Cox marginal structural model to assess the comparative effectiveness of inhaled corticosteroids versus no inhaled corticosteroid treatment in chronic obstructive pulmonary disease. Ann Epidemiol 2021; 67:19-28. [PMID: 34798296 DOI: 10.1016/j.annepidem.2021.11.004] [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] [Received: 04/30/2021] [Revised: 10/20/2021] [Accepted: 11/04/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the potential of a Cox marginal structural model (MSM) to estimate the time-varying causal inference of a known clinical trial association where the effectiveness of inhaled corticosteroid- (ICS-) versus non-ICS-containing treatments has been compared in patients with chronic obstructive pulmonary disease (COPD). METHODS This retrospective study from 2006 to 2016 used linked data from Clinical Practice Research Datalink-GOLD, Hospital Episode Statistics and Office for National Statistics mortality. A Cox MSM, incorporating a new-user design, was deemed capable of replicating a clinical trial-like pathway. Repeated outcomes for exacerbation events and stabilised weights were used to include time-varying and fixed covariate exposures. RESULTS Of 45,958 patients, 55% were male; 52% had moderate COPD. ICS-treated patients had a higher incidence of comorbid asthma than non-ICS-treated patients. Adjusted hazard risk ratios for any exacerbation event: ICS/long-acting β2-agonist (LABA) versus long-acting muscarinic antagonist (LAMA), 1.07 (95% confidence interval 1.04-1.10); ICS/LABA versus LABA/LAMA, 1.05 (1.00-1.10); ICS/LABA/LAMA versus LAMA, 1.04 (1.01-1.06); ICS/LABA/LAMA versus LABA/LAMA 1.02 (0.97-1.07). CONCLUSIONS The Cox MSM was not able to fully demonstrate results consistent with the previously established benefits of ICS-containing treatments seen in clinical trials. Future studies should continue to investigate causal inference methods and their capability to estimate the long-term outcomes of treatment in COPD.
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Affiliation(s)
- Claudia Cabrera
- Real World Science and Digital, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden.
| | | | - Mario Ouwens
- Real World Science and Digital, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | | | - Jennifer K Quint
- National Heart & Lung Institute, Imperial College London, London, UK
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13
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Singh D, Holmes S, Adams C, Bafadhel M, Hurst JR. Overcoming Therapeutic Inertia to Reduce the Risk of COPD Exacerbations: Four Action Points for Healthcare Professionals. Int J Chron Obstruct Pulmon Dis 2021; 16:3009-3016. [PMID: 34754186 PMCID: PMC8570921 DOI: 10.2147/copd.s329316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/18/2021] [Indexed: 12/26/2022] Open
Abstract
Background Therapeutic inertia, defined as failure to escalate or initiate adequate therapy when treatment goals are not met, contributes to poor management of COPD exacerbations. Methods A multidisciplinary panel of five expert clinicians actively managing COPD and representative of UK practice developed action points to reduce exacerbation risk, based on evidence, clinical expertise, and experience. The action points are applicable despite changing circumstances (eg, virtual clinics). The panel agreed areas where further evidence is needed. Results The four action points were (1) an experienced HCP, such as a GP or member of the multi-professional COPD team should review patients within one month of every exacerbation that requires oral steroids, antibiotics, or hospitalization to address modifiable risk factors, optimize non-pharmacological measures, and evaluate pharmacological therapy. (2) Presenting to hospital with an exacerbation defines an important window of opportunity to reduce the risk of further exacerbations. Follow-up by a GP, or member of the multi-professional specialist COPD team within one month of discharge with a full management review and appropriate escalation of pharmacological treatment is essential. (3) Healthcare professionals (HCPs) in all healthcare settings should be able to recognize COPD exacerbations, refer as appropriate and document the episode accurately in medical records across service boundaries. HCPs should support patients to recognize and report exacerbations. (4) HCPs should intervene proactively based on risk assessments, disease activity and any treatable traits at or as soon as possible after diagnosis and annually thereafter. Delivering these action points needs coordinated action with policymakers, funders, and service providers. Conclusion These action points should be a fundamental part of clinical practice to determine if a change in management is necessary to reduce the risk of exacerbations. Policymakers should use these action points to develop systems and initiatives that reduce the risk of further exacerbations.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester, UK
| | | | - Claire Adams
- Tees Valley Clinical Commissioning Group, Middlesbrough, UK
| | - Mona Bafadhel
- Nuffield Department Clinical Medicine, University of Oxford, Oxford, UK
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
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14
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Nikolaou V, Massaro S, Garn W, Fakhimi M, Stergioulas L, Price DB. Fast decliner phenotype of chronic obstructive pulmonary disease (COPD): applying machine learning for predicting lung function loss. BMJ Open Respir Res 2021; 8:8/1/e000980. [PMID: 34716217 PMCID: PMC8559126 DOI: 10.1136/bmjresp-2021-000980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/19/2021] [Indexed: 12/31/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of lung conditions challenging to diagnose and treat. Identification of phenotypes of patients with lung function loss may allow early intervention and improve disease management. We characterised patients with the ‘fast decliner’ phenotype, determined its reproducibility and predicted lung function decline after COPD diagnosis. Methods A prospective 4 years observational study that applies machine learning tools to identify COPD phenotypes among 13 260 patients from the UK Royal College of General Practitioners and Surveillance Centre database. The phenotypes were identified prior to diagnosis (training data set), and their reproducibility was assessed after COPD diagnosis (validation data set). Results Three COPD phenotypes were identified, the most common of which was the ‘fast decliner’—characterised by patients of younger age with the lowest number of COPD exacerbations and better lung function—yet a fast decline in lung function with increasing number of exacerbations. The other two phenotypes were characterised by (a) patients with the highest prevalence of COPD severity and (b) patients of older age, mostly men and the highest prevalence of diabetes, cardiovascular comorbidities and hypertension. These phenotypes were reproduced in the validation data set with 80% accuracy. Gender, COPD severity and exacerbations were the most important risk factors for lung function decline in the most common phenotype. Conclusions In this study, three COPD phenotypes were identified prior to patients being diagnosed with COPD. The reproducibility of those phenotypes in a blind data set following COPD diagnosis suggests their generalisability among different populations.
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Affiliation(s)
| | - Sebastiano Massaro
- University of Surrey, Surrey Business School, Guildford, UK.,The Organizational Neuroscience Laboratory, London, UK
| | - Wolfgang Garn
- University of Surrey, Surrey Business School, Guildford, UK
| | - Masoud Fakhimi
- University of Surrey, Surrey Business School, Guildford, UK
| | | | - David B Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK.,Optimum Patient Care, Cambridge, UK.,Observational and Pragmatic Research Institute, Singapore
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15
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Pullen R, Miravitlles M, Sharma A, Singh D, Martinez F, Hurst JR, Alves L, Dransfield M, Chen R, Muro S, Winders T, Blango C, Muellerova H, Trudo F, Dorinsky P, Alacqua M, Morris T, Carter V, Couper A, Jones R, Kostikas K, Murray R, Price DB. CONQUEST Quality Standards: For the Collaboration on Quality Improvement Initiative for Achieving Excellence in Standards of COPD Care. Int J Chron Obstruct Pulmon Dis 2021; 16:2301-2322. [PMID: 34413639 PMCID: PMC8370848 DOI: 10.2147/copd.s313498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/30/2021] [Indexed: 12/17/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) are managed predominantly in primary care. However, key opportunities to optimize treatment are often not realized due to unrecognized disease and delayed implementation of appropriate interventions for both diagnosed and undiagnosed individuals. The COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST) is the first-of-its-kind, collaborative, interventional COPD registry. It comprises an integrated quality improvement program focusing on patients (diagnosed and undiagnosed) at a modifiable and higher risk of COPD exacerbations. The first step in CONQUEST was the development of quality standards (QS). The QS will be imbedded in routine primary and secondary care, and are designed to drive patient-centered, targeted, risk-based assessment and management optimization. Our aim is to provide an overview of the CONQUEST QS, including how they were developed, as well as the rationale for, and evidence to support, their inclusion in healthcare systems. Methods The QS were developed (between November 2019 and December 2020) by the CONQUEST Global Steering Committee, including 11 internationally recognized experts with a specialty and research focus in COPD. The process included an extensive literature review, generation of QS draft wording, three iterative rounds of review, and consensus. Results Four QS were developed: 1) identification of COPD target population, 2) assessment of disease and quantification of future risk, 3) non-pharmacological and pharmacological intervention, and 4) appropriate follow-up. Each QS is followed by a rationale statement and a summary of current guidelines and research evidence relating to the standard and its components. Conclusion The CONQUEST QS represent an important step in our aim to improve care for patients with COPD in primary and secondary care. They will help to transform the patient journey, by encouraging early intervention to identify, assess, optimally manage and followup COPD patients with modifiable high risk of future exacerbations.
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Affiliation(s)
- Rachel Pullen
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Anita Sharma
- Platinum Medical Centre, Chermside, QLD, Australia
| | - Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fernando Martinez
- New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Luis Alves
- EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - Mark Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rongchang Chen
- Key Laboratory of Respiratory Disease of Shenzhen, Shenzhen Institute of Respiratory Disease, Shenzhen People’s Hospital (Second Affiliated Hospital of Jinan University, First Affiliated Hospital of South University of Science and Technology of China), Shenzhen, People's Republic of China
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Nara, Japan
| | - Tonya Winders
- USA & Global Allergy & Airways Patient Platform, Vienna, Austria
| | - Christopher Blango
- Janssen Pharmaceutical Companies of Johnson & Johnson, Philadelphia, PA, USA
| | | | | | | | | | | | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
| | - Amy Couper
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
| | - Rupert Jones
- Research and Knowledge Exchange, Plymouth Marjon University, Plymouth, UK
| | - Konstantinos Kostikas
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Ruth Murray
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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