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Tashkin DP, Barjaktarevic I, Gomez-Seco J, Behbehani NH, Koltun A, Siddiqui UA. Prevalence and Management of Chronic Obstructive Pulmonary Disease in the Gulf Countries with a Focus on Inhaled Pharmacotherapy. J Aerosol Med Pulm Drug Deliv 2024. [PMID: 38813999 DOI: 10.1089/jamp.2023.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a preventable, progressive disease and the third leading cause of death worldwide. The epidemiological data of COPD from Gulf countries are very limited, as it remains underdiagnosed and underestimated. Risk factors for COPD include tobacco cigarette smoking, water pipe smoking (Shisha), exposure to air pollutants, occupational dusts, fumes, and chemicals. Inadequate treatment of COPD leads to worsening of disease. The 2024 GOLD guidelines recommend use of inhaled bronchodilators, corticosteroids, and adjunct therapies for treatment and management of COPD patients based on an individual assessment of the severity of symptoms and risk of exacerbations. This article reviews COPD pharmacotherapy in the Gulf countries and explores the role of nebulization in the management of COPD in this region. Methods: To review the COPD pharmacotherapy in the Gulf Countries, literature search was conducted using PubMed, Medline, Cochrane Systematic Reviews, and Google Scholar databases (before December 2022), using search terms such as COPD, nebulization, inhalers/inhalation, aerosols, and Gulf countries. Relevant articles from the reference list of identified studies were reviewed. Consensus statements, expert opinion, and other published review articles were included. Results: In the Gulf countries, pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs), soft mist inhalers, and nebulizers are used for drug delivery to COPD patients. pMDIs and DPIs are most prone to errors in technique and other common device handling errors. Nebulization is another mode of inhalation drug delivery, which is beneficial in certain patient populations such as the elderly and patients with cognitive impairment, motor or neuromuscular disorders, and other comorbidities. Conclusion: There is no major difference between Gulf countries and rest of the world in the approach to management of COPD. Nebulizers should be considered for patients who have difficulties in accessing or using MDIs and DPIs, irrespective of geographical location.
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Affiliation(s)
- Donald P Tashkin
- David Geffen School of Medicine at UCLA Health Sciences, Los Angeles, California, USA
| | | | - Julio Gomez-Seco
- Department of Pulmonology, Fakeeh University Hospital, Dubai, United Arab Emirates
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Pelaia C, Ferrante Bannera A, Rotundo FL, Tropea FG, Armentaro G, Maglio A, Sciacqua A, Vatrella A, Pelaia G. Clinical and Functional Effects of Inhaled Dual Therapy Umeclidinium/Vilanterol in Patients with Chronic Obstructive Pulmonary Disease: A Real-Life Study. Int J Chron Obstruct Pulmon Dis 2023; 18:995-1002. [PMID: 37260547 PMCID: PMC10228585 DOI: 10.2147/copd.s407238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023] Open
Abstract
Background The pharmacological association umeclidinium/vilanterol (UMEC/VI) allows to implement a very effective dual bronchodilation in chronic obstructive pulmonary disease (COPD), thus optimizing bronchodilating therapy. Methods The main purpose of our real-world observational study was to evaluate in COPD patients the effects of UMEC/VI on lung function and respiratory symptoms. Functional and clinical parameters were assessed at baseline, and after 52 weeks of treatment with this combined double inhaled therapy. Results We enrolled 110 subjects suffering from COPD. A 12-month UMEC/VI treatment induced significant improvements in total lung capacity (TLC) (p < 0.05), and residual volume (RV) (p < 0.0001). Pulmonary deflation was paralleled by significant increases of forced expiratory volume in one second (FEV1) (p < 0.0001), forced vital capacity (FVC) (p < 0.01), forced expiratory flow between 25% and 75% of FVC (FEF25-75) (p < 0.0001) and diffusion capacity of the lung (DLCOcSB) (p < 0.05). In addition, in the same period, we also observed significant reductions of airway resistance including total resistance (Rtot) (p < 0.0001) and specific effective resistance (sReff) (p < 0.0001). Other improvements were detected with regard to modified British Medical Research Council (mMRC) questionnaire score (p < 0.0001), COPD Assessment Test (CAT) score (p < 0.0001), and COPD exacerbation rate (p < 0.0001). In particular, the reported changes of mMRC/CAT scores and COPD exacerbation numbers were significantly correlated with UMEC/VI-induced modifications of TLC, RV, FVC and FEV1. Conclusion In conclusion, our study corroborates in a real-life context the effectiveness of UMEC/VI in COPD treatment. Indeed, our broad investigational strategy has allowed to better characterize the functional mechanisms underpinning the therapeutic properties of UMEC/VI association.
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Affiliation(s)
- Corrado Pelaia
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
| | - Anna Ferrante Bannera
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
| | | | | | - Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
| | - Angelantonio Maglio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
| | - Alessandro Vatrella
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Girolamo Pelaia
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
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Miravitlles M, Kawayama T, Dreher M. LABA/LAMA as First-Line Therapy for COPD: A Summary of the Evidence and Guideline Recommendations. J Clin Med 2022; 11:jcm11226623. [PMID: 36431099 PMCID: PMC9692772 DOI: 10.3390/jcm11226623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/27/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022] Open
Abstract
Inhaled bronchodilators (alone or in combination) are the cornerstone of treatment for symptomatic patients with COPD, either as initial/first-line treatment or for second-line/treatment escalation in patients who experience persistent symptoms or exacerbations on monotherapy. The Global Initiative for Chronic Obstructive Lung Disease 2022 report recommends initial pharmacological treatment with a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA) as monotherapy for most patients, or dual bronchodilator therapy (LABA/LAMA) in patients with more severe symptoms, regardless of exacerbation history. The recommendations for LABA/LAMA are broader in the American Thoracic Society treatment guidelines, which strongly recommend LABA/LAMA combination therapy over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance. However, despite consistent guideline recommendations, real-world prescribing data indicate that LAMA and/or LABA without an inhaled corticosteroid are not the most widely prescribed therapies in COPD. This article reviews global and regional/national guideline recommendations for the use of LABA/LAMA in COPD, examines the evidence for the effectiveness and safety of LABA/LAMA versus other therapies and offers a practical guide for clinicians to help ensure appropriate use of LABA/LAMA therapy.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d′Hebron, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Correspondence: ; Tel.: +34-(93)-274-6157
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, 52074 Aachen, Germany
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4
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Salvi S, Jain MK, Krishnamurthy S, Balki A, Kodgule R, Tandon M, Bhagat S, Panchal S, Khatri N, Wu W, Pendse A, Patil S, Barkate H. Comparative efficacy and safety of glycopyrronium/formoterol fixed-dose combination versus glycopyrronium monotherapy in patients with moderate-to-severe COPD. Lung India 2022; 39:517-524. [PMID: 36629230 PMCID: PMC9746267 DOI: 10.4103/lungindia.lungindia_136_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 08/04/2022] [Indexed: 01/12/2023] Open
Abstract
Background The safety and efficacy of fixed-dose combination (FDC) of glycopyrronium bromide 12.5 μg/formoterol fumarate 12 μg (GB/FF) twice daily as dry powder inhalers (DPIs) compared to glycopyrronium 50 μg monotherapy (GLY) once daily as DPI in subjects with moderate-to-severe chronic obstructive pulmonary disease (COPD) were evaluated. Methods This was a phase-3, randomized, double-blind, active-controlled, parallel-group, superiority study conducted in India. COPD patients aged ≥40 to ≤65 years, current or ex-smokers with FEV1/FVC <0.70, using ICS, LAMA, or LABA for ≥1 month were included. Subjects were randomized (1:1) to GB/FF or GLY for 12 weeks. The primary efficacy endpoint was the change from baseline in peak FEV1 at the end of 12 weeks. The study is registered with the Clinical Trials Registry of India (CTRI/2017/02/007814). Results Between March 2017 and July 2018, 331 patients were enrolled and randomized into GB/FF FDC (165 patients) and GLY monotherapy (166 patients) groups. At week 12, the difference in change from baseline in the peak FEV1 for GB/FF DPI versus GLY was 0.115 L (SE = 0.02; 95% CI = 0.061, 0.170; P < 0.0001). Trough FEV1 increased significantly in the GB/FF group compared to the GLY group with a treatment difference of 0.078 L (SE = 0.02; 95% CI = 0.015, 0.14; P = 0.01). There were no significant differences in adverse events between the groups. Conclusion FDC of GB/FF (12.5/12 μg twice daily) as a DPI provides superior bronchodilation and lung function improvement over GLY (50 μg once daily) monotherapy. It is safe and well tolerated in symptomatic COPD patients.
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Affiliation(s)
- Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, Maharashtra, India
| | - Manish K. Jain
- Department of Respiratory, Maharaja Agrasen Superspeciality Hospital, Jaipur, Rajasthan, India
| | - Srikanth Krishnamurthy
- Department of Pulmonary and Respiratory Medicine, Sri Bala Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
| | - Akash Balki
- Shree Hospital and Critical Care, Nagpur, Maharashtra, India
| | - Rahul Kodgule
- Clinical Development, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Monika Tandon
- Clinical Development, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Sagar Bhagat
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Sagar Panchal
- Ex-Employee, Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Nishtha Khatri
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Wen Wu
- Clinical Operations, Glenmark Pharmaceuticals Ltd., Waterford, UK
| | - Amol Pendse
- Clinical Operations, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Saiprasad Patil
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Hanmant Barkate
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
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Salvi S, Kumar A, Agrawal S, Leuva A, Shukla VK, Deshpande SV, Balamurugan S, Singh A, Tikkiwal S, Gupta SK, Singh BP, Lopez M, Sawant S, Vaidya A, Gogtay J. Efficacy and safety of glycopyrronium/formoterol delivered via a dry powder inhaler in patients with moderate to severe chronic obstructive pulmonary disease: Results from a multi-centre, open-label, randomised study. Lung India 2022; 39:408-416. [PMID: 36629200 PMCID: PMC9623852 DOI: 10.4103/lungindia.lungindia_92_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 01/14/2023] Open
Abstract
Background We designed this randomised, open-label, parallel group, multi-centre study to investigate the efficacy and safety of glycopyrronium/formoterol, a long-acting muscarinic antagonist/long-acting β2-agonist fixed dose combination, delivered through a dry powder inhaler (DPI) in patients with chronic obstructive pulmonary disease (COPD). Material and Methods We randomised (1:1) patients with moderate to severe COPD (N = 356) to receive glycopyrronium 25 μg/formoterol 12 μg via DPI twice daily (GF-DPI) or glycopyrronium 50 μg monotherapy via DPI once daily (G-DPI). The primary study endpoint was the mean change from the baseline in pre-dose trough-forced expiratory volume in one second (FEV1) at 12 weeks. Results At week 12, the mean increase from the baseline in pre-dose trough FEV1 was higher in the GF-DPI group (120 ml) than in the G-DPI (60 ml) group. The mean difference (MD) between treatment groups was 0.06 L (95% CI: 0.00-0.12 L, P < 0.0001 for non-inferiority). At week 12, the mean pre-dose forced vital capacity (FVC), 1 hour post-dose FEV1, and post-dose FVC increased significantly from the baseline only in the GF-DPI group (p < 0.0001). The reduction in the COPD assessment test score was greater in the GF-DPI group (p = 0.0379). The average daily number of puffs of rescue medication and the reduction in mean modified Medical Research Council scale, COPD, and Asthma Sleep Impact Scale score at week 12 were similar between groups (p > 0.05). Overall, 35 adverse events and two serious adverse events unrelated to study drugs were reported. Both groups had similar results for overall drug safety. Conclusion The results demonstrate efficacy and safety of GF-DPI in Indian patients with moderate to severe COPD. Treatment with GF-DPI significantly improved the lung function and quality of life and was well tolerated.
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Affiliation(s)
- Sundeep Salvi
- Department of Pulmonology, Pulmocare Research and Education Faith Centre, Pune, Maharashtra, India
| | - Anand Kumar
- Department of Pulmonology, GSVM Medical College, Kanpur, Uttar Pradesh, India
| | - Sumit Agrawal
- Department of Pulmonology, Oyster and Pearl Hospital, Pune, Maharashtra, India
| | - Amritlal Leuva
- Department of Chest and TB, Shree Sayaji General Hospital and Government Medical College, Vadodara, Gujarat, India
| | - Vineet Kumar Shukla
- Department of Pulmonology, KRM Hospital and Research Centre, Lucknow, Uttar Pradesh, India
| | - Shrikant Vishnu Deshpande
- Department of General Medicine, Dr. Deshpande’s Ashirwad Hospital and Research Center, Ulhasnagar, Maharashtra, India
| | - Santhalingam Balamurugan
- Department of Pulmonology, Sri Muthukumaran Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India
| | - Ajit Singh
- Department of Pulmonology, SMS Hospital and Medical College, Jaipur, Rajasthan, India
| | - Sharad Tikkiwal
- Department of Pulmonology, Asthma Bhawan, Jaipur, Rajasthan, India
| | - Sandeep K. Gupta
- Department of Medicine, M.V. Hospital and Research Center, Lucknow, Uttar Pradesh, India
| | - Bhanu Pratap Singh
- Department of Pulmonary Medicine, Miland Healthcare, Lucknow, Uttar Pradesh, India
| | - Meena Lopez
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
| | - Sandesh Sawant
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
| | - Abhijit Vaidya
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
| | - Jaideep Gogtay
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
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Rodrigues SDO, da Cunha CMC, Soares GMV, Silva PL, Silva AR, Gonçalves-de-Albuquerque CF. Mechanisms, Pathophysiology and Currently Proposed Treatments of Chronic Obstructive Pulmonary Disease. Pharmaceuticals (Basel) 2021; 14:979. [PMID: 34681202 PMCID: PMC8539950 DOI: 10.3390/ph14100979] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/13/2021] [Accepted: 08/28/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the leading global causes of morbidity and mortality. A hallmark of COPD is progressive airflow obstruction primarily caused by cigarette smoke (CS). CS exposure causes an imbalance favoring pro- over antioxidants (oxidative stress), leading to transcription factor activation and increased expression of inflammatory mediators and proteases. Different cell types, including macrophages, epithelial cells, neutrophils, and T lymphocytes, contribute to COPD pathophysiology. Alteration in cell functions results in the generation of an oxidative and inflammatory microenvironment, which contributes to disease progression. Current treatments include inhaled corticosteroids and bronchodilator therapy. However, these therapies do not effectively halt disease progression. Due to the complexity of its pathophysiology, and the risk of exacerbating symptoms with existing therapies, other specific and effective treatment options are required. Therapies directly or indirectly targeting the oxidative imbalance may be promising alternatives. This review briefly discusses COPD pathophysiology, and provides an update on the development and clinical testing of novel COPD treatments.
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Affiliation(s)
- Sarah de Oliveira Rodrigues
- Laboratório de Imunofarmacologia, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil;
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
- Programa de Pós-Graduação em Ciências e Biotecnologia, Universidade Federal Fluminense, Rio de Janeiro 24020-140, Brazil
| | - Carolina Medina Coeli da Cunha
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
| | - Giovanna Martins Valladão Soares
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
| | - Pedro Leme Silva
- Laboratório de Investigação Pulmonar, Carlos Chagas Filho, Instituto de Biofísica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil;
| | - Adriana Ribeiro Silva
- Laboratório de Imunofarmacologia, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil;
- Programa de Pós-Graduação em Ciências e Biotecnologia, Universidade Federal Fluminense, Rio de Janeiro 24020-140, Brazil
- Programa de Pós-Graduação em Biologia Celular e Molecular, Instituto Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil
| | - Cassiano Felippe Gonçalves-de-Albuquerque
- Laboratório de Imunofarmacologia, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil;
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
- Programa de Pós-Graduação em Ciências e Biotecnologia, Universidade Federal Fluminense, Rio de Janeiro 24020-140, Brazil
- Programa de Pós-Graduação em Biologia Molecular e Celular, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20210-010, Brazil
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Pasqua E, Hamblin N, Edwards C, Baker-Glenn C, Hurley C. Developing inhaled drugs for respiratory diseases: A medicinal chemistry perspective. Drug Discov Today 2021; 27:134-150. [PMID: 34547449 DOI: 10.1016/j.drudis.2021.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 07/11/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022]
Abstract
Despite the devastating impact of many lung diseases on human health, there is still a significant unmet medical need in respiratory diseases, for which inhaled delivery represents a crucial strategy. More guidance on how to design and carry out multidisciplinary inhaled projects is needed. When designing inhaled drugs, the medicinal chemist must carefully balance the physicochemical properties of the molecule to achieve optimal target engagement in the lung. Although the medicinal chemistry strategy is unique for each project, and will change depending on multiple factors, such as the disease, target, systemic risk, delivery device, and formulation, general guidelines aiding inhaled drug design can be applied and are summarised in this review.
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Affiliation(s)
- Elisa Pasqua
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK.
| | - Nicole Hamblin
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK; Charles River Laboratories, Chesterford Research Park, Saffron Waldon CB10 1XL, UK
| | - Christine Edwards
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK
| | - Charles Baker-Glenn
- Charles River Laboratories, Chesterford Research Park, Saffron Waldon CB10 1XL, UK
| | - Chris Hurley
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK
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Román-Rodríguez M, Kocks JWH. Targeting exertional breathlessness to improve physical activity: the role of primary care. NPJ Prim Care Respir Med 2021; 31:41. [PMID: 34504091 PMCID: PMC8429707 DOI: 10.1038/s41533-021-00254-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/19/2021] [Indexed: 02/08/2023] Open
Abstract
Primary care physicians (PCPs) play a crucial role in the diagnosis and management of chronic obstructive pulmonary disease (COPD). By working together with patients to target exertional breathlessness and increase physical activity, PCPs have an important role to play, early in the disease course, in improving patient outcomes in both the short and long term. In this article, we consider how physical activity affects disease progression from the PCP perspective. We discuss the role of pharmacological therapy, the importance of an holistic approach and the role of PCPs in assessing and promoting physical activity. The complexity and heterogeneity of COPD make it a challenging disease to treat. Patients' avoidance of activity, and subsequent decline in capacity to perform it, further impacts the management of the disease. Improving patient tolerance of physical activity, increasing participation in daily activities and helping patients to remain active are clear goals of COPD management. These may require an holistic approach to management, including pulmonary rehabilitation and psychological programmes in parallel with bronchodilation therapy, in order to address both physiological and behavioural factors. PCPs have an important role to optimise therapy, set goals and communicate the importance of maintaining physical activity to their patients. In addition, optimal treatment that addresses activity-related breathlessness can help prevent the downward spiral of inactivity and get patients moving again, to improve their overall health and long-term prognosis.
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Affiliation(s)
- Miguel Román-Rodríguez
- Son Pisà Primary Health Care Centre, Balearic Health System, Mallorca, Spain.
- Primary Care Chronic Respiratory Research Unit, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Mallorca, Spain.
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
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Dual LABA/LAMA Therapy versus LABA or LAMA Monotherapy for Chronic Obstructive Pulmonary Disease. A Systematic Review and Meta-analysis in Support of the American Thoracic Society Clinical Practice Guideline. Ann Am Thorac Soc 2021; 17:1133-1143. [PMID: 32530702 DOI: 10.1513/annalsats.201912-915oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: There is uncertainty on the optimal first-line therapy for symptomatic chronic obstructive pulmonary disease (COPD). Long-acting β2-receptor agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) have long been mainstays of treatment, though it is still not clear if dual therapy with LABA/LAMA is superior to monotherapy for symptomatic COPD.Objectives: To clarify the evidence landscape, we conducted a systematic review to answer the following question: in patients with COPD who complain of dyspnea and/or exercise intolerance, is LABA/LAMA combination therapy more effective and equally safe compared with LABA or LAMA monotherapy?Methods: A search of Medline, EMBASE, and the Cochrane Library databases was conducted by a medical librarian for randomized controlled trials enrolling patients with COPD who complain of dyspnea and/or exercise intolerance that compare LABA/LAMA combination therapy to LABA or LAMA monotherapy. A systematic approach was used to screen, abstract, and critically appraise the emerging study evidence. The Grading of Recommendations Assessment, Development, and Evaluation method was applied to rate the certainty and quality of the evidence.Results: A total of 24 studies were eligible for inclusion (n = 45,441). Pairwise random-effects meta-analysis revealed reductions in hospital admissions (11% reduction; P < 0.01) and acute exacerbations of COPD (20% reduction; P < 0.002), all in favor of LABA/LAMA dual therapy. Although there is reduced dyspnea (0.10 standardized mean difference; P < 0.001) and improved health-related quality of life (-0.13 standardized mean difference; P < 0.001), both values did not meet a clinical meaningful difference threshold. LABA/LAMA combination therapy showed no difference in treatment-emergent adverse effects (risk ratio, 0.99; P = 0.34) when compared with either LAMA or LABA monotherapy.Conclusions: Based on the reviewed evidence, in patients with symptomatic COPD who complain of dyspnea and/or exercise intolerance, dual LABA/LAMA therapy is superior to either LABA or LAMA monotherapy based on the reduced risk of exacerbations and hospitalizations.
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10
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Pelaia C, Procopio G, Deodato MR, Florio O, Maglio A, Sciacqua A, Vatrella A, Pelaia G. Real-Life Clinical and Functional Effects of Fluticasone Furoate/Umeclidinium/Vilanterol-Combined Triple Therapy in Patients with Chronic Obstructive Pulmonary Disease. Respiration 2020; 100:127-134. [PMID: 33302284 DOI: 10.1159/000512064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/29/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Triple therapy consisting of a drug association including an inhaled corticosteroid, a long-acting muscarinic receptor antagonist and a long-acting β2-adrenergic agonist, delivered via a single device, can be a valuable treatment for chronic obstructive pulmonary disease (COPD) patients experiencing frequent disease exacerbations. OBJECTIVES The aim of this real-life, single-center, observational study was to evaluate, in 44 COPD patients with recurrent exacerbations, the effects of the triple inhaled therapy combining fluticasone furoate, umeclidinium, and vilanterol (FF/UMEC/VI). METHODS Within such a therapeutic context, several clinical and lung functional parameters were considered at baseline and after 24 weeks of treatment with combined inhaled triple therapy. RESULTS With respect to baseline, after 24 weeks of treatment with FF/UMEC/VI, significant changes were recorded with regard to Modified British Medical Research Council (p < 0.0001) and COPD Assessment Test (p < 0.0001) scores, COPD exacerbations (p < 0.001), forced expiratory volume in the first second (p < 0.001), residual volume (p < 0.01), forced mid-expiratory flow between 25 and 75% of FVC (p < 0.0001), inspiratory capacity (p < 0.01), forced vital capacity (p < 0.05), and peak expiratory flow (p < 0.0001). Moreover, in a subgroup of 28 patients, a significant increase of diffusion lung capacity (p < 0.01) was also detected. CONCLUSIONS In conclusion, our real-life results suggest that triple inhaled therapy with FF/UMEC/VI, when given to COPD patients with frequent exacerbations, is able to positively impact on dyspnea and global health status as well as to significantly decrease COPD exacerbations and improve airflow limitation and lung hyperinflation.
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Affiliation(s)
- Corrado Pelaia
- Respiratory Medicine Unit, University "Magna Græcia" of Catanzaro, Catanzaro, Italy,
| | - Giada Procopio
- Respiratory Medicine Unit, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | | | - Olivia Florio
- Respiratory Medicine Unit, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | - Angelantonio Maglio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | - Alessandro Vatrella
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Girolamo Pelaia
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
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Parikh TJ, Stryczek KC, Gillespie C, Sayre GG, Feemster L, Udris E, Majerczyk B, Rinne ST, Wiener RS, Au DH, Helfrich CD. Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids. PLoS One 2020; 15:e0238511. [PMID: 32941462 PMCID: PMC7498097 DOI: 10.1371/journal.pone.0238511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). Methods We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%). Results The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient’s fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a ‘security blanket’. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication. Conclusions While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.
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Affiliation(s)
- Toral J. Parikh
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | | | - Chris Gillespie
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, United States of America
| | - George G. Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Laura Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, United States of America
| | - Edmunds Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
| | - Barbara Majerczyk
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
| | - Seppo T. Rinne
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, United States of America
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, United States of America
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - David H. Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, United States of America
| | - Christian D. Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, United States of America
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12
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Calverley PMA, Hoz ADL, Xue W, Ferguson GT, Miravitlles M. COPD Maintenance Therapy with Tiotropium/Olodaterol Compared with Tiotropium: An Analysis in the Absence of Additional ICS Therapy. COPD 2020; 17:477-484. [PMID: 32928003 DOI: 10.1080/15412555.2020.1813269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The American Thoracic Society guidelines recommend long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) dual bronchodilation over LAMA or LABA monotherapy as maintenance therapy for patients with chronic obstructive pulmonary disease suffering from dyspnea or exercise intolerance. Previous studies, which included patients receiving background inhaled corticosteroids (ICS), have shown the benefits of dual bronchodilation over monotherapy. This analysis aimed to confirm the benefits of LAMA/LABA over LAMA alone, without any confounding effects from ICS use. This pooled post hoc analysis compared the efficacy of tiotropium/olodaterol with tiotropium alone in patients from the TONADO® and OTEMTO® clinical trials who were not receiving ICS at study entry or during the studies. We analyzed change from baseline in trough forced expiratory volume in 1 s (FEV1), St. George's Respiratory Questionnaire (SGRQ) score and Transition Dyspnea Index (TDI) score in all patients, by Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, baseline SGRQ score, and Baseline Dyspnea Index score. In this analysis of 1596 patients, tiotropium/olodaterol improved trough FEV1, SGRQ and TDI compared with tiotropium alone. The observed mean differences were: trough FEV1, 0.054 L (95% confidence interval [CI] 0.036, 0.073; p < 0.001); SGRQ, -1.918 (95% CI -2.994, -0.843; p < 0.001); and TDI, 0.575 (95% CI 0.301, 0.848; p < 0.001). Similar improvements were seen in each of the subgroup analyses. Tiotropium/olodaterol therapy significantly improved lung function, symptoms and health status compared with tiotropium alone. In a population free from ICS treatment, these data confirm the benefits of dual bronchodilation versus monotherapy.
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Affiliation(s)
- Peter M A Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wenqiong Xue
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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13
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Buhl R, Singh D, de la Hoz A, Xue W, Ferguson GT. Benefits of Tiotropium/Olodaterol Compared with Tiotropium in Patients with COPD Receiving only LAMA at Baseline: Pooled Analysis of the TONADO ® and OTEMTO ® Studies. Adv Ther 2020; 37:3485-3499. [PMID: 32462607 PMCID: PMC7370969 DOI: 10.1007/s12325-020-01373-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report recommends long-acting muscarinic antagonists (LAMA) or long-acting β2-agonists (LABA) as first-line treatment for chronic obstructive pulmonary disease (COPD), but many patients remain symptomatic on monotherapy and escalation to dual-bronchodilator therapy may be warranted. METHODS TONADO® 1&2 and OTEMTO® 1&2 assessed lung function and patient-reported outcomes in patients with moderate-to-severe (OTEMTO) or moderate-to-very-severe (TONADO) COPD. This pooled post hoc analysis included patients treated with LAMA monotherapy at baseline who were randomised to receive either 5 µg tiotropium (LAMA) or 5/5 µg tiotropium/olodaterol (LAMA/LABA). We assessed changes from baseline and responder rates for trough forced expiratory volume in 1 s (FEV1), St. George's Respiratory Questionnaire (SGRQ) and the Transition Dyspnoea Index (TDI). RESULTS Overall, 151 patients received tiotropium; 148 received tiotropium/olodaterol. Mean differences from baseline with tiotropium/olodaterol versus tiotropium were + 0.074 l (95% confidence interval [CI] 0.033, 0.115; P = 0.0004) for trough FEV1, - 2.675 (95% CI - 5.060, - 0.291; P = 0.0280) for SGRQ and 1.148 (95% CI 0.564, 1.732; P = 0.0001) for TDI. Patients were more likely to respond when treated with tiotropium/olodaterol versus tiotropium for trough FEV1 (odds ratio [OR] 3.14, 95% CI 1.94, 5.06; P < 0.0001), SGRQ (OR 1.49, 95% CI 0.93, 2.40; P = 0.0980) and TDI (OR 2.81, 95% CI 1.71, 4.60; P < 0.0001). Minimum clinically important difference from baseline in any of the analysed outcomes (FEV1 ≥ 0.1 l, SGRQ ≥ 4.0 points or TDI ≥ 1.0 point) was more likely in patients treated with tiotropium/olodaterol versus tiotropium (OR 2.43, 95% CI 1.32, 4.51; P = 0.0046). CONCLUSION In patients with COPD receiving only LAMA monotherapy, treatment escalation to tiotropium/olodaterol resulted in statistically significant and clinically relevant improvements in lung function, health status and breathlessness. These results support early therapy optimisation to dual bronchodilation with tiotropium/olodaterol in patients receiving tiotropium alone. TRIAL REGISTRATION TONADO® 1 was registered in the US National Library of Medicine on 9 September 2011 (Clinicaltrials.gov: NCT01431274). TONADO® 2 was registered in the US National Library of Medicine on 9 September 2011 (Clinicaltrials.gov: NCT01431287). OTEMTO® 1 was registered in the US National Library of Medicine on 17 October 2013 (Clinicaltrials.gov: NCT01964352). OTEMTO® 2 was registered in the US National Library of Medicine on 10 December 2013 (Clinicaltrials.gov: NCT02006732).
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Johannes Gutenberg University Hospital, Mainz, Germany.
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wenqiong Xue
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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14
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Anzueto A, Miravitlles M. Tiotropium in chronic obstructive pulmonary disease - a review of clinical development. Respir Res 2020; 21:199. [PMID: 32727455 PMCID: PMC7389564 DOI: 10.1186/s12931-020-01407-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background Bronchodilators are the mainstay of pharmacological treatment in chronic obstructive pulmonary disease (COPD), and long-acting muscarinic antagonist (LAMA) monotherapy is recommended as initial treatment for Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, and D. Main body Tiotropium bromide was the first LAMA available for COPD in clinical practice and, because of its long duration of action, is administered once daily. Tiotropium was initially available as an inhalation powder delivered via a dry-powder inhaler (DPI). Later, tiotropium also became available as an inhalation spray delivered via a soft mist inhaler (SMI). The SMI was designed to overcome or minimize some of the issues associated with other inhaler types (eg, the need for strong inspiratory airflow with DPIs). Results of short- and long-term randomized, controlled clinical trials of tiotropium in patients with COPD indicated tiotropium was safe and significantly improved lung function, health-related quality of life, and exercise endurance, and reduced dyspnea, lung hyperinflation, exacerbations, and use of rescue medication compared with placebo or active comparators. These positive efficacy findings triggered the evaluation of tiotropium in fixed-dose combination with olodaterol (a long-acting β2-agonist). In this review, we provide an overview of studies of tiotropium for the treatment of COPD, with a focus on pivotal studies. Conclusion Tiotropium is safe and efficacious as a long-term, once-daily LAMA for the maintenance treatment of COPD and for reducing COPD exacerbations. The SMI generates a low-velocity, long-duration aerosol spray with a high fine-particle fraction, which results in marked lung drug deposition. In addition, high inspiratory flow rates are not required.
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Affiliation(s)
- Antonio Anzueto
- Internal Medicine, Pulmonary Disease, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitary Vall d'Hebron/Vall d'Hebron Research Institute (VHIR). CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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