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Rana RH, Alam K, Keramat SA, Gow J. Cost-effectiveness of single-inhaler triple therapy for patients with severe COPD: A systematic literature review. Expert Rev Respir Med 2022; 16:1067-1084. [DOI: 10.1080/17476348.2022.2145951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rezwanul Hasan Rana
- Centre for the Health Economy, Macquarie University, Macquarie Park, Australia
- Australian Institute of Health and Innovation, Macquarie University, Macquarie Park, Australia
| | - Khorshed Alam
- University of Southern Queensland, Toowoomba, Australia
| | | | - Jeff Gow
- University of Southern Queensland, Toowoomba, Australia
- School of Accounting, Economics and Finance, University of KwaZulu-Natal, Durban, South Africa
- Department of Agricultural Economics, Stellenbosch University, Stellenbosch, South Africa
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Cook J, Bloom C, Lewis J, Marjenberg Z, Platz JH, Langham S. Impact of health technology assessment on prescribing patterns of inhaled fixed-dose combination triple therapy in chronic obstructive pulmonary disease. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2021; 9:1929757. [PMID: 34122781 PMCID: PMC8174477 DOI: 10.1080/20016689.2021.1929757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/03/2021] [Accepted: 05/07/2021] [Indexed: 06/12/2023]
Abstract
Background: Evidence suggests that triple therapy for patients with chronic obstructive pulmonary disease (COPD) is being used in a broader range of patients than recommended by guidelines, which may have health and cost implications. Objective: To explore the relationship between national health technology assessment (HTA) agency appraisals and market penetration of two fixed-dose combination (FDC) triple therapies. Study design: HTAs from Q3 2017 to Q1 2020 from 10 countries were evaluated. Intervention: Glycopyrronium bromide/formoterol fumarate/beclomethasone (Trimbow®) and umeclidinium/vilanterol/fluticasone furoate (Trelegy™ Ellipta®). Main outcome measure: HTA restrictions and prescribing rates (days of therapy). Results: Seven countries (70%) imposed restrictions on use including prescription only for patients stable on free-combination triple therapy or not controlled on dual therapy, requirement of a specialist prescription or therapeutic plan, prescription only for patients with severe COPD, and use as second-line therapy or later. In general, countries that have imposed restrictions on the use of FDC triple therapies have seen a lower than average uptake. Conclusion: Payer guidance on prescribing FDC triple therapy may potentially support more appropriate prescribing in line with clinical guidelines. It is important for payers to consider which restrictions would ensure the most efficient use of scarce resources.
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Affiliation(s)
- Jennifer Cook
- TA Cardio Metabolism Respiratory Global Market Access, Boehringer Ingelheim GmbH, Ingelheim Am Rhein, Germany
| | - Chloe Bloom
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London
| | | | | | - Jaime Hernando Platz
- TA Cardio Metabolism Respiratory Global Market Access, Boehringer Ingelheim GmbH, Ingelheim Am Rhein, Germany
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Single-inhaler triple therapy in patients with chronic obstructive pulmonary disease: a systematic review. Respir Res 2019; 20:242. [PMID: 31684965 PMCID: PMC6829989 DOI: 10.1186/s12931-019-1213-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Guidelines recommend that treatment with a long-acting β2 agonist (LABA), a long-acting muscarinic antagonist (LAMA), and inhaled corticosteroids (ICS), i.e. triple therapy, is reserved for a select group of symptomatic patients with chronic obstructive pulmonary disease (COPD) who continue to exacerbate despite treatment with dual therapy (LABA/LAMA). A number of single-inhaler triple therapies are now available and important clinical questions remain over their role in the patient pathway. We compared the efficacy and safety of single-inhaler triple therapy to assess the magnitude of benefit and to identify patients with the best risk-benefit profile for treatment. We also evaluated and compared study designs and population characteristics to assess the strength of the evidence base. Methods We conducted a systematic search, from inception to December 2018, of randomised controlled trials (RCTs) of single-inhaler triple therapy in patients with COPD. The primary outcome was the annual rate of moderate and severe exacerbations. Results We identified 523 records, of which 15 reports/abstracts from six RCTs were included. Triple therapy resulted in the reduction of the annual rate of moderate or severe exacerbations in the range of 15–52% compared with LAMA/LABA, 15–35% compared to LABA/ICS and 20% compared to LAMA. The patient-based number needed to treat for the moderate or severe exacerbation outcome ranged between approximately 25–50 (preventing one patient from having an event) and the event-based number needed to treat of around 3–11 (preventing one event). The absolute benefit appeared to be greater in patients with higher eosinophil counts or historical frequency of exacerbations and ex-smokers. In the largest study, there was a significantly higher incidence of pneumonia in the triple therapy arm. There were important differences in study designs and populations impacting the interpretation of the results and indicating there would be significant heterogeneity in cross-trial comparisons. Conclusion The decision to prescribe triple therapy should consider patient phenotype, magnitude of benefit and increased risk of adverse events. Future research on specific patient phenotype thresholds that can support treatment and funding decisions is now required from well-designed, robust, clinical trials. Trial registration PROSPERO #CRD42018102125.
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Dobler CC, Farah MH, Morrow AS, Alsawas M, Benkhadra R, Hasan B, Prokop LJ, Wang Z, Murad MH. Treatment of stable chronic obstructive pulmonary disease: protocol for a systematic review and evidence map. BMJ Open 2019; 9:e027935. [PMID: 31061055 PMCID: PMC6501947 DOI: 10.1136/bmjopen-2018-027935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/29/2019] [Accepted: 04/02/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a progressive lung disease, usually caused by tobacco smoking, but other important risk factors include exposures to combustion products of biomass fuels and environmental pollution. The introduction of several new (combination) inhaler therapies, increasing uncertainty about the role of inhaled corticosteroids and a rapid proliferation of the literature on management of stable COPD in general, call for novel ways of evidence synthesis in this area. A systematic review and evidence map can provide the basis for shared decision-making tools and help to establish a future research agenda. METHODS AND ANALYSIS This systematic review will follow an umbrella systematic review design (also called overview of reviews). We plan to conduct a comprehensive literature search of Ovid MEDLINE (including epub ahead of print, in process and other non-indexed citations), Ovid Embase, Ovid Cochrane Database of Systematic Reviews and Scopus from database inception to the present. We will include systematic reviews that assessed the effectiveness of any pharmacological or non-pharmacological intervention on one or more patient-important outcomes and/or lung function in patients with stable COPD. For every intervention/outcome pair, one systematic review will be included. An a priori protocol will guide, which systematic reviews will be chosen, how their credibility will be evaluated, and how the quality of the body of evidence will be rated. Data will be synthesised into an evidence map that will present a matrix that depicts each available treatment for stable COPD with a quantitative estimate on symptoms/outcomes from the patient perspective, along with an indication of the size and certainty in the evidence. ETHICS AND DISSEMINATION Approval by a research ethics committee is not required since the review will only include published data. The systematic review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018095079.
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Affiliation(s)
- Claudia C Dobler
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Magdoleen H Farah
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allison S Morrow
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouaz Alsawas
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Raed Benkhadra
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bashar Hasan
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Zhen Wang
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Zheng Y, Zhu J, Liu Y, Lai W, Lin C, Qiu K, Wu J, Yao W. Triple therapy in the management of chronic obstructive pulmonary disease: systematic review and meta-analysis. BMJ 2018; 363:k4388. [PMID: 30401700 PMCID: PMC6218838 DOI: 10.1136/bmj.k4388] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the rate of moderate to severe exacerbations between triple therapy and dual therapy or monotherapy in patients with chronic obstructive pulmonary disease (COPD). DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES PubMed, Embase, Cochrane databases, and clinical trial registries searched from inception to April 2018. ELIGIBILITY CRITERIA Randomised controlled trials comparing triple therapy with dual therapy or monotherapy in patients with COPD were eligible. Efficacy and safety outcomes of interest were also available. DATA EXTRACTION AND SYNTHESIS Data were collected independently. Meta-analyses were conducted to calculate rate ratios, hazard ratios, risk ratios, and mean differences with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations assessment, development, and evaluation). RESULTS 21 trials (19 publications) were included. Triple therapy consisted of a long acting muscarinic antagonist (LAMA), long acting β agonist (LABA), and inhaled corticosteroid (ICS). Triple therapy was associated with a significantly reduced rate of moderate or severe exacerbations compared with LAMA monotherapy (rate ratio 0.71, 95% confidence interval 0.60 to 0.85), LAMA and LABA (0.78, 0.70 to 0.88), and ICS and LABA (0.77, 0.66 to 0.91). Trough forced expiratory volume in 1 second (FEV1) and quality of life were favourable with triple therapy. The overall safety profile of triple therapy is reassuring, but pneumonia was significantly higher with triple therapy than with dual therapy of LAMA and LABA (relative risk 1.53, 95% confidence interval 1.25 to 1.87). CONCLUSIONS Use of triple therapy resulted in a lower rate of moderate or severe exacerbations of COPD, better lung function, and better health related quality of life than dual therapy or monotherapy in patients with advanced COPD. STUDY REGISTRATION Prospero CRD42018077033.
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Affiliation(s)
- Yayuan Zheng
- Laboratory of Physiological Sciences and Department of Pharmacy of the Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang, China
| | - Jianhong Zhu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuyu Liu
- Department of Pharmacology, Guangdong Medical University, Zhanjiang, China
| | - Weiguang Lai
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
| | - Chunyu Lin
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
| | - Kaifen Qiu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junyan Wu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Weimin Yao
- Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, No 57, South of Renmin Avenue, Zhanjiang 524001, China
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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: 50] [Impact Index Per Article: 8.3] [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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Zhao S, Yang Q, Yu Z, Lv Y, Zhi J, Gustin P, Zhang W. Protective effects of tiotropium alone or combined with budesonide against cadmium inhalation induced acute neutrophilic pulmonary inflammation in rats. PLoS One 2018; 13:e0193610. [PMID: 29489916 PMCID: PMC5831634 DOI: 10.1371/journal.pone.0193610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/14/2018] [Indexed: 11/19/2022] Open
Abstract
As a potent bronchodilator, the anti-inflammatory effects of tiotropium and its interaction with budesonide against cadmium-induced acute pulmonary inflammation were investigated. Compared to values obtained in rats exposed to cadmium, cytological analysis indicated a significant decrease of total cell and neutrophil counts and protein concentration in bronchoalveolar lavage fluid (BALF) in rats pretreated with tiotropium (70μg/15ml or 350μg/15ml). Zymographic tests showed a decrease of MMP-2 activity in BALF in rats pretreated only with high concentration of tiotropium. Histological examination revealed a significant decrease of the severity and extent of inflammatory lung injuries in rats pretreated with both tested concentrations of tiotropium. Though tiotropium (70μg/15ml) or budesonide (250μg/15ml) could not reduce cadmium-induced bronchial hyper-responsiveness, their combination significantly decreased bronchial contractile response to methacholine. These two drugs separately decreased the neutrophil number and protein concentration in BALF but no significant interaction was observed when both drugs were combined. Although no inhibitory effects on MMP-2 and MMP-9 was observed in rats pretreated with budesonide alone, the combination with the ineffective dose of tiotropium induced a significant reduction on these parameters. The inhibitory effect of tiotropium on lung injuries was not influenced by budesonide which alone induced a limited action on the severity and extent of inflammatory sites. Our findings show that tiotropium exerts anti-inflammatory effects on cadmium-induced acute neutrophilic pulmonary inflammation. The combination of tiotropium with budesonide inhibits cadmium-induced inflammatory injuries with a synergistic interaction on MMP-2 and MMP-9 activity and airway hyper-responsiveness.
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Affiliation(s)
- Shiwei Zhao
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Yang
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhixi Yu
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - You Lv
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianming Zhi
- Department of Anatomy and Physiology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pascal Gustin
- Department for Functional Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Wenhui Zhang
- Department of Anatomy and Physiology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- * E-mail:
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Gillissen A, Haidl P, Kohlhäufl M, Kroegel K, Voshaar T, Gessner C. The Pharmacological Treatment of Chronic Obstructive Pulmonary Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:311-6. [PMID: 27215595 PMCID: PMC4961886 DOI: 10.3238/arztebl.2016.0311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are markedly less effective against chronic obstructive pulmonary disease (COPD) than against asthma, and also have worse side effects. Whether ICS should be used to treat COPD is currently a matter of debate. METHODS This review is based on pertinent articles retrieved by a selective search in PubMed and the Excerpta Medica Database (EMBASE) carried out in May 2015. We analyzed clinical trials of ICS for the treatment of COPD with a duration of at least one year, along with meta-analyses and COPD guidelines. RESULTS ICS lower the frequency and severity of COPD exacerbations in comparison to monotherapy with a long-acting ß2-agonist, but have no effect on mortality. Compared to placebo, ICS monotherapy lessens the decline of forced expiratory volume in one second (FEV1) over one year by merely 5.80 mL (statistically insignificant; 95% confidence interval: [-0.28; 11.88]) and only marginally improve quality of life. ICS use in patients with COPD increases the risk of pneumonia. A combination of ICS with a long-acting bronchodilator improves FEV1 by 133 mL [105; 161] and lowers the frequency of severe exacerbations by 39% . The frequency of exacerbations is lowered mainly in patients who have many exacerbations; thus, ICS treatment is suitable only for patients with grade III or IV COPD. CONCLUSION ICS monotherapy has no clinically useful effect on pulmonary function in COPD. The main form of drug treatment for COPD is with broncho - dilators, either alone or in combination with ICS. ICS can be given to patients with grade III or IV COPD to make exacerbations less frequent. Patients with an asthma-COPD overlap syndrome (ACOS) can benefit from ICS treatment.
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Affiliation(s)
| | - Peter Haidl
- Fachkrankenhaus Kloster Grafschaft, Schmallenberg
| | | | - Klaus Kroegel
- Department of Internal Medicine I: Pneumology & Allergology/Immunology, Friedrich Schiller University Jena
| | - Thomas Voshaar
- Department of Pneumology and Allergy, Medical Clinic III, Bethanien Hospital Moers
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