Cost-effectiveness of long-acting bronchodilators for chronic obstructive pulmonary disease

Respiratory questionnaire-based analysis of awareness of COPD in a large multicenter rural population-based study in India

Background

Chronic obstructive pulmonary disease (COPD) is a more prevalent chronic lung disease with a significant health burden, and the majority of these cases receive inadequate treatment.

Methods

Prospective, observational, interview (questionnaire) based complete workup COPD study, screened 12,000 cases with chronic respiratory symptoms with cough, sputum production, and shortness of breath. A total of 6000 COPD cases were enrolled after the spirometry test. COPD cases were assessed as disease knowledge and methods of treatment offered by applying questionnaires to patients and treating physicians.

Results

In the present study, 3% of study cases were aware of their COPD illness, 54% were not having knowledge about the disease, and 43% cases were not accepting the COPD diagnosis (p < 0.0001). A total of 58% of cases received inhalation treatment as levosalbutamol monotherapy in 31% cases, levosalbutamol plus beclometasone in 18% cases, and formoterol plus budesonide or salmeterol plus fluticasone only in 9% of COPD cases (p < 0.0001). Total 42% cases received oral treatment as theophylline in 16% cases, salbutamol in 7% cases, oral steroids in 19% cases (p < 0.0001).

Conclusion

"Doctor-patient-drug trio" discordance clubbed as "difficult doctor, difficult patient, and difficult treatment" is a very crucial issue observed during diagnosis and management of COPD in peripheral settings in India.

Mapping analysis to estimate EQ-5D utility values using the COPD assessment test in Korea

Background

There is no research on mapping algorithms between EQ-5D and COPD assessment test (CAT) in Korea. The purpose of this study was to develop mapping algorithms that predict EQ-5D-3 L utility from the CAT in patients with COPD.

Methods

Survey data of 300 COPD patients were collected from three tertiary teaching hospitals in Korea. To predict EQ-5D-3 L utility from the CAT, various models were assessed. Models were developed using randomly split training samples. Subsequently, the models were validated based on root mean square error (RMSE) and mean absolute error (MAE) in validation samples. The models were also validated using the bootstrap method, which involves iterative splitting, training, and validating of the sample data at least 10,000 times. Average RMSEs and MAEs were used as criteria for model selection.

Results

The recommended mapping algorithms were based on ordinary least squares (OLS) regression models, which revealed five CAT items (chest tightness, breathlessness, activity, leaving home, and energy) as statistically significant on the EQ-5D-3 L. The mapping models estimated the overall mean of EQ-5D-3 L utilities effectively, but EQ-5D-3 L utilities for severe (low utility) patients (< 0.6) were overestimated as the observed EQ-5D-3 L utilities were often distributed over 0.6.

Conclusion

Mapping algorithms can be used to predict EQ-5D-3 L utilities from the CAT. However, mapping algorithms should be used cautiously when applied to groups with greater disease severity.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1148-3) contains supplementary material, which is available to authorized users.

Simulation-Based Estimates of the Effectiveness and Cost-Effectiveness of Pulmonary Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease in France

BACKGROUND

The medico-economic impact of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) is poorly documented.

OBJECTIVE

To estimate the effectiveness and cost-effectiveness of pulmonary rehabilitation in a hypothetical cohort of COPD patients.

METHODS

We used a multi-state Markov model, adopting society's perspective. Simulated cohorts of French GOLD stage 2 to 4 COPD patients with and without pulmonary rehabilitation were compared in terms of life expectancy, quality-adjusted life years (QALY), disease-related costs, and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses included variations of key model parameters.

PRINCIPAL FINDINGS

At the horizon of a COPD patient's remaining lifetime, pulmonary rehabilitation would result in mean gain of 0.8 QALY, with an over disease-related costs of 14 102 € per patient. The ICER was 17 583 €/QALY. Sensitivity analysis showed that pulmonary rehabilitation was cost-effective in every scenario (ICER <50 000 €/QALY).

CONCLUSIONS

These results should provide a useful basis for COPD pulmonary rehabilitation programs.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

Systematic review of models used in economic analyses in moderate-to-severe asthma and COPD

BACKGROUND

Respiratory diseases exert a substantial burden on society, with newer drugs increasingly adding to the burden. Economic models are often used, but seldom reviewed.

PURPOSE

To summarize economic models used in economic analyses of drugs treating moderate-to-severe/very severe asthma or chronic obstructive pulmonary disease (COPD).

METHODS

This study searched Medline and Embase from inception to the end of February 2015 for cost-effectiveness/utility analyses that examined at least one drug against placebo, another drug, or other standard therapy in asthma or COPD. Two reviewers independently searched and extracted data with differences adjudicated via consensus discussion. Data extracted included model used and its qualities, validation methods, treatments compared, disease severity, analytic perspective, time horizon, data collection (pro- or retrospective), input rates and sources, costs and sources, planned sensitivity analyses, criteria for cost-effectiveness, reported outcomes, and sponsor.

RESULTS

This study analyzed 53 articles; 14 (25%) on asthma and 39 (75%) COPD. Markov models were commonly used for both asthma and COPD-related economic evaluations. Relatively few studies validated their model. For asthma-related studies, 10 examined inhaled corticosteroids and nine studied omalizumab. Placebo or standard therapy was the comparison in 11 studies and active drugs in the remainder.

CONCLUSIONS

Few studies include validation of their models. Furthermore, controversy concerning some results was uncovered in this study, which needs to be avoided in the future.

Comparative efficacy of long-acting muscarinic antagonists in preventing COPD exacerbations: a network meta-analysis and meta-regression

Background:

We hypothesized a class effect of currently available long-acting muscarinic antagonists (LAMAs; i.e. tiotropium as a dry powder inhaler or a soft mist inhaler, aclidinium bromide, and glycopyrronium) in preventing chronic obstructive pulmonary disease (COPD) exacerbations. The hypothesis was tested with a network meta-analysis.

Methods:

Several databases and manufacturer’s websites were searched for relevant clinical trials. Randomized, controlled trials, of at least 12 weeks duration, comparing a LAMA with placebo or another LAMA were included. Moderate-to-severe and severe exacerbations were chosen as the outcome assessment criteria. The data were pooled using network meta-analysis.

Results:

A total of 27 studies with 48,140 subjects were included. All LAMAs reduced moderate-to-severe exacerbations compared with placebo. However, there were no statistically significant differences in preventing moderate-to-severe or severe exacerbations among LABAs. In a subgroup analysis restricting studies to those that had a minimum of 6 months of treatment, glycopyrronium was associated with the least-effective strategy and aclidinium was associated with the greatest probability of being the best therapy in preventing severe exacerbations. Our meta-regression analysis suggested that the prevention of COPD exacerbations were less effective in studies which allowed concomitant use of a long-acting beta agonist (LABA).

Conclusion:

All LAMAs were equally effective in preventing moderate-to-severe exacerbations. Aclidinium was associated with the lowest risk for severe exacerbations when treatment duration was 6 months or longer. The concomitant use of LABA may not enhance the efficacy of LAMAs in preventing COPD exacerbations. More studies are needed to further examine above findings.

Self-management support for moderate-to-severe chronic obstructive pulmonary disease: a pilot randomised controlled trial

BACKGROUND

Better self management could improve quality of life (QoL) and reduce hospital admissions in chronic obstructive pulmonary disease (COPD), but the best way to promote it remains unclear.

AIM

To explore the feasibility, effectiveness and cost effectiveness of a novel, layperson-led, theoretically driven COPD self-management support programme.

DESIGN AND SETTING

Pilot randomised controlled trial in one UK primary care trust area.

METHOD

Patients with moderate to severe COPD were identified through primary care and randomised 2:1 to the 7-week-long, group intervention or usual care. Outcomes at baseline, 2, and 6 months included self-reported health, St George's Respiratory Questionnaire (SGRQ), EuroQol, and exercise.

RESULTS

Forty-four per cent responded to GP invitation, 116 were randomised: mean (standard deviation [SD]) age 69.5 (9.8) years, 46% male, 78% had unscheduled COPD care in the previous year. Forty per cent of intervention patients completed the course; 35% attended no sessions; and 78% participants completed the 6-month follow-up questionnaire. Results suggest that the intervention may increase both QoL (mean EQ-5D change 0.12 (95% confidence interval [CI] = -0.02 to 0.26) higher, intervention versus control) and exercise levels, but not SGRQ score. Economic analyses suggested that with thresholds of £20 000 per quality-adjusted life-year gained, the intervention is likely to be cost-effective.

CONCLUSION

This intervention has good potential to meet the UK National Institute for Health and Clinical Excellence criteria for cost effectiveness, and further research is warranted. However, to make a substantial impact on COPD self-management, it will also be necessary to explore other ways to enable patients to access self-management education.

Tiotropium versus long-acting beta-agonists for stable chronic obstructive pulmonary disease

BACKGROUND

Tiotropium and long-acting beta(2)-agonists (LABAs) are both accepted in the routine management for people with stable chronic obstructive pulmonary disease (COPD). There are new studies which have compared tiotropium with LABAs, including some that have evaluated recently introduced LABAs.

OBJECTIVES

To compare the relative clinical effects of tiotropium bromide alone versus LABA alone, upon measures of quality of life, exacerbations, lung function and serious adverse events, in people with stable COPD.To critically appraise and summarise current evidence on the costs and cost-effectiveness associated with tiotropium compared to LABA in people with COPD.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register of trials and economic evaluations from searching NHS EED and HEED (date of last search February 2012). We found additional trials from web-based clinical trial registers.

SELECTION CRITERIA

We included RCTs and full economic evaluations if they compared effects of tiotropium alone with LABAs alone in people with COPD. We allowed co-administration of standard COPD therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, then extracted data on study quality and outcomes. We contacted study authors and trial sponsors for additional information. We analysed data using the Cochrane Review Manager(RevMan 5.1) software.

MAIN RESULTS

Seven clinical studies totalling 12,223 participants with COPD were included in the review. The studies used similar designs and were generally of good methodological quality. Inclusion criteria for RCTs were similar across the included studies, although studies varied in terms of smoking history and COPD severity of participants. They compared tiotropium (which was delivered by HandiHaler in all studies) with salmeterol (four studies, 8936 participants), formoterol (one study, 431 participants) and indacaterol (two studies, 2856 participants). All participants were instructed to discontinue anticholinergic or long-acting beta(2)-agonist bronchodilators during treatment, but could receive inhaled corticosteroids (ICS) at a stable dose. Study duration ranged from 3 to 12 months. We extracted data for 11,223 participants. In general, the treatment groups were well matched at baseline. Overall, the risk of bias across the included RCTs was low.In the analysis of the primary outcomes in this review, a high level of heterogeneity amongst studies meant that we did not pool data for St George's Respiratory Questionnaire quality of life score. Subgroup analyses based on the type of LABA found statistically significant differences among effects on quality of life depending on whether tiotropium was compared with salmeterol, formoterol or indacaterol. Tiotropium reduced the number of participants experiencing one or more exacerbations compared with LABA (odds ratio (OR) 0.86; 95% confidence interval (CI) 0.79 to 0.93). For this outcome, there was no difference seen among the different types of LABA. There was no statistical difference in mortality observed between the treatment groups.For secondary outcomes, tiotropium was associated with a reduction in the number of COPD exacerbations leading to hospitalisation compared with LABA treatment (OR 0.87; 95% 0.77 to 0.99), but not in the overall rate of all-cause hospitalisations. There was no statistically significant difference in forced expiratory volume in one second (FEV(1)) or symptom score between tiotropium and LABA-treated participants. There was a lower rate of non-fatal serious adverse events recorded with tiotropium compared with LABA (OR 0.88; 95% CI 0.78 to 0.99). The tiotropium group was also associated with a lower rate of study withdrawals (OR 0.89; 95% CI 0.81 to 0.99).We identified six full economic evaluations assessing the cost and cost-effectiveness of tiotropium and salmeterol. The studies were based on an economic model or empirical analysis of clinical data from RCTs. They all looked at maintenance costs and the costs for COPD exacerbations, including respiratory medications and hospitalisations. The setting for the evaluations was primary and secondary care in the UK, Greece, Netherlands, Spain and USA. All the studies estimated tiotropium to be superior to salmeterol based on better clinical outcomes (exacerbations or quality of life) and/or lower total costs. However, the authors of all evaluations reported there was substantial uncertainty around the results.

AUTHORS' CONCLUSIONS

In people with COPD, the evidence is equivocal as to whether or not tiotropium offers greater benefit than LABAs in improving quality of life; however, this is complicated by differences in effect among the LABA types. Tiotropium was more effective than LABAs as a group in preventing COPD exacerbations and disease-related hospitalisations, although there were no statistical differences between groups in overall hospitalisation rates or mortality during the study periods. There were fewer serious adverse events and study withdrawals recorded with tiotropium compared with LABAs. Symptom improvement and changes in lung function were similar between the treatment groups. Given the small number of studies to date, with high levels of heterogeneity among them, one approach may be to give a COPD patient a substantial trial of tiotropium, followed by a LABA (or vice versa), then to continue prescribing the long-acting bronchodilator that the patient prefers. Further studies are needed to compare tiotropium with different LABAs, which are currently ongoing. The available economic evidence indicates that tiotropium may be cost-effective compared with salmeterol in several specific settings, but there is considerable uncertainty around this finding.

A 36-month study on the cost/utility of add-on omalizumab in persistent difficult-to-treat atopic asthma in Italy

OBJECTIVE

Omalizumab is a biological treatment for difficult-to-treat allergic asthma. Its mechanism of action relies on impeding the binding of immunoglobulin E (IgE) to specific cellular receptors, thus blocking the inflammatory cascade. At present, no long-term data are available on its cost/effectiveness. The aim of this study is to assess long-term clinical outcomes and to measure the cost/utility of long-term omalizumab use in difficult-to-treat allergic asthmatics.

METHODS

The clinical, economic, and quality-of-life (QoL) outcomes of 36-month add-on omalizumab therapy were compared to equivalent outcomes for the year before the therapy's introduction in a cohort (n = 16) of adults with severe uncontrolled atopic asthma on chronic high-dose antiasthma treatments. The variables considered were lung function, IgE levels, health status, Asthma Control Test (ACT) score, QoL (St. George Questionnaire), general practitioner (GP) and specialist visits, number and duration of hospitalizations, emergency room admission, and pharmacological treatment (both dose and duration). Derived calculated indicators were changes in health-related QoL, total healthcare costs, and incremental cost/utility. Data from the two periods were tested for statistically significant differences according to Student's t test and p < .05 was accepted.

RESULTS

Add-on omalizumab significantly and progressively improved asthma control and patient health-related QoL. Symptomatic drug and hospital care costs for these patients dropped significantly. A €450 increase in overall monthly costs was observed; however, when health benefits were considered, this cost increase translated into an incremental cost/utility ratio of €23,880 per quality-adjusted life year gained, which is quite a favorable and convenient figure in terms of the willingness to pay for health benefits in industrialized countries.

CONCLUSIONS

The 36-month add-on omalizumab therapy persistently improved all clinical outcomes in difficult-to-treat asthmatic patients. Costs were also optimized and related to the extent of long-term health benefits achieved.

Cost effectiveness of pharmacological maintenance treatment for chronic obstructive pulmonary disease: a review of the evidence and methodological issues

BACKGROUND

Over 200 million people have chronic obstructive pulmonary disease (COPD) worldwide. The number of disease-year equivalents and deaths attributable to COPD are high. Guidelines for the pharmacological treatment of the disease recommend an individualized step-up approach in which treatment is intensified when results are unsatisfactory.

OBJECTIVE

Our objective was to present a systematic review of the cost effectiveness of pharmacological maintenance treatment for COPD and to discuss the methodological strengths and weaknesses of the studies.

METHODS

A systematic literature search for economic evaluations of drug therapy in COPD was performed in MEDLINE, EMBASE, the Economic Evaluation Database of the UK NHS (NHS-EED) and the European Network of Health Economic Evaluation Databases (EURONHEED). Full economic evaluations presenting both costs and health outcomes were included.

RESULTS

A total of 40 studies were included in the review. Of these, 16 were linked to a clinical trial, 14 used Markov models, eight were based on observational data and two used a different approach. The few studies on combining short-acting bronchodilators were consistent in finding net cost savings compared with monotherapy. Studies comparing inhaled corticosteroids (ICS) with placebo or no maintenance treatment reported inconsistent results. Studies comparing fluticasone with salmeterol consistently found salmeterol to be more cost effective. The cost-effectiveness studies of tiotropium versus placebo, ipratropium or salmeterol pointed towards a reduction in total COPD-related healthcare costs for tiotropium in many but not all studies. All of these studies reported additional health benefits of tiotropium. The cost-effectiveness studies of the combination of inhaled long-acting β₂-agonists and ICS all report additional health benefits at an increase in total COPD-related costs in most studies. The cost-per-QALY estimates of this combination treatment vary widely and are very sensitive to the assumptions on mortality benefit and time horizon.

CONCLUSIONS

The currently available economic evaluations indicate differences in cost effectiveness between COPD maintenance therapies, but for a more meaningful comparison of results it is important to improve the consistency with respect to study methodology and choice of comparator.

A review of cost-effectiveness of varenicline and comparison of cost-effectiveness of treatments for major smoking-related morbidities

RATIONALE

This review aims to examine economic evaluations of varenicline, to compare the reported cost-effectiveness of varenicline with that of treatments for major smoking-related diseases and to evaluate the findings for decision making.

METHODS

A literature search was performed to identify published articles in English indexed in MEDLINE and the Cochrane Library (Issue 1, 2009), which includes the Economic Evaluation Database. Additional sources also were searched to identify unpublished varenicline studies, including conference abstracts. The search for varenicline studies was limited from 2006 to October 2009; searches for all other types of studies were limited from 1990 to October 2009.

RESULTS

The search yielded a total of 20 relevant economic evaluations of varenicline. In addition, 37 reviews of economic evaluations in chronic obstructive pulmonary disease, non-small cell lung cancer and cardiovascular disease, as well as studies evaluating the impact of economic rewarding were considered in this review. From these identified economic evaluations, the incremental cost-effectiveness ratios for varenicline ranged from dominance (more effective and cost saving) to €18,582 per quality-adjusted life-year (including indirect costs). These estimates appeared substantially lower when compared with incremental cost-effectiveness ratios reported for secondary prevention of smoking-related diseases, which in some cases were as high as €66,218 per quality-adjusted life-year.

CONCLUSIONS

Varenicline appears to be cost-effective from the perspective of both health care payers and employers, because of reduced health care consumption and costs. The cost-effectiveness of varenicline also compares favourably to that of interventions recommended for the treatment and prevention of smoking-related diseases.

Tiotropium's cost-effectiveness for the treatment of COPD: a cost-utility analysis under real-world conditions

BACKGROUND

Tiotropium is reimbursed since March 2004 in Belgium for the treatment of Chronic Obstructive Pulmonary Disease (COPD). Questions however remain on this product's value for money. The purpose of this study is to calculate tiotropium's cost-effectiveness under real-world conditions.

METHODS

Strengths of both observational and RCT data were combined in a model. A large longitudinal (2002-2006) observational dataset of regular tiotropium users (56,321 patients) was analysed to retrieve the baseline risk for exacerbations and exacerbation-related hospitalisations the year before the first delivery of tiotropium. The relative treatment effect from the UPLIFT (Understanding Potential Long-term Impacts on Function with Tiotropium) trial was then applied to this baseline risk to reflect the effect of tiotropium treatment and calculate the intervention's incremental cost-effectiveness ratio (ICER).

RESULTS

After 1000 Latin Hypercube simulations, the incremental benefit expressed as quality-adjusted life years (QALY) gained is on average 0.00048 (95% confidence interval (CI) 0.00009-0.00092). In combination with a substantial mean incremental cost of €373 per patient (95% CI 279-475), this results in an unfavourable average ICER of €1,244,023 (95% CI 328,571-4,712,704) per QALY gained. Results were most sensitive to the treatment effect on hospitalisations. Based on our large observational database, up to 89% of the patients were not hospitalised for COPD in the year before the first tiotropium delivery.

CONCLUSIONS

The main cause for tiotropium's unfavourable cost-effectiveness ratio is a combination of a relative high price for tiotropium, a low number of hospitalisations without tiotropium treatment (on average 0.14/year) and a non-significant treatment effect (on average 0.94) with respect to avoiding exacerbation-related hospitalisations. From an economic point of view, a revision of reimbursement modalities (e.g. with a lower price) would be justified and would entail a more efficient use of resources.

Cost effectiveness of tiotropium for chronic obstructive pulmonary disease: a systematic review of the evidence

BACKGROUND

Tiotropium has been shown to reduce exacerbations and improve quality of life for patients with chronic obstructive pulmonary disease (COPD), a lung disease characterized by a persistent and progressive airflow limitation.

OBJECTIVES

To present a systematic literature review of the cost effectiveness of treatment with tiotropium compared with other currently used treatments for COPD.

METHODS

A systematic search was performed via PubMed, the Cochrane database, and EMBASE from 2002 to 2009. Methods and results by study design and by country were compared.

RESULTS

Seventeen studies were included in the review. Study designs were characterized as follows: modeling based on clinical trial data, and empirical analysis based on either clinical trial or observational data. Comparing monotherapy regimens (12 studies), all study designs found that treatment with tiotropium was associated with lower costs for hospitalisation and other non-drug services. Total costs, including the costs of maintenance drugs, were lower with tiotropium in some, but not all, of the studies. Tiotropium was shown to be cost effective based on commonly accepted benchmark values. Limitations of the review included the wide variety of outcome measures used in different studies, the limited number of observational database studies for monotherapy, and limited data for combination therapy regimens.

CONCLUSIONS

The main conclusions of the economic evaluations derived from clinical trial data at the time of product approval and from later observational data reflecting clinical use are similar: use of tiotropium monotherapy is associated with lower hospital and other non-drug costs and better health outcomes and is either cost saving or cost effective compared with other maintenance monotherapies.

Sequential comparison of tiotropium to high-dose ipratropium in patients with chronic obstructive pulmonary disease in a practice setting

OBJECTIVE

To determine the effect of changing anticholinergic therapy in patients with COPD from ipratropium to tiotropium on pulmonary function.

METHODS

We examined records of patients prescribed high-dose ipratropium, who were subsequently converted to tiotropium. Spirometric values were obtained within 2 days of the change in medication and after 56 to 224 days of the switch to tiotropium.

RESULTS

15 subjects were documented to have filled a prescription for ipratropium-containing medications the month prior to the change. Medication compliance over the 6 months prior to the switch in these patients was 72% +/- 31% (mean +/- SD) for ipratropium compared to 87% +/- 14% for tiotropium over the 6-month period after the switch (P = 0.1). FEV(1) improved from 1.12 +/- 0.39 L at baseline to 1.37 +/- 0.49 L after the change to tiotropium (P = 0.01). FVC also improved from 2.45 +/- 0.73 L at baseline to 2.72 +/- 0.69 L after the change (P = 0.04). Maximal voluntary ventilation was also increased from 39.67 +/- 10.7 L/min to 45.13 +/- 15.8 L/min (P = 0.045).

CONCLUSIONS

We conclude that replacing high-dose ipratropium with tiotropium therapy significantly improves pulmonary function in a clinical setting.

Medication adherence issues in patients treated for COPD

Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

Long-Acting Bronchodilator Therapy for the Treatment of Chronic Obstructive Pulmonary Disease

Objective:

To review clinical data on the use of long-acting bronchodilator agents as monotherapy and in combination for the treatment of moderate-to-severe chronic obstructive pulmonary disease (COPD).

Data Sources:

A literature search was performed via MEDLINE (1966–April 2008). In addition, references from publications identified were reviewed. These searches were limited to human data published in the English language. Searches used the following terms: COPD, long-acting β2-agonisls, long-acting anticholinergics, combination therapy, pharmacoeconomics, safety, tiotropium, salmeterol, and formoterol.

Study Selection and Data Extraction:

Relevant information on the pharmacology, safety, efficacy, pharmacoeconomics, adherence, and available agents used in the treatment of COPD was selected. Randomized clinical trials and retrospective reviews were included.

Data Synthesis:

The Global Initiative for Chronic Obstructive Lung Disease guidelines provide general management recommendations to guide providers regarding treatment choices for COPD; however, they lack clarity regarding which long-acting bronchodilator to use and when combining agents becomes appropriate. Prospective trials evaluating short-acting anticholinergics and long-acting β2-agonists have utilized spirometric endpoints that relate most to short-term symptomatic relief. Tiotropium trials have focused more on patient-oriented outcomes, with data being reported for one year. Tiotropium significantly lowers exacerbation rates and improves health resource usage as well as health-related quality of life. Tiotropium also provides superior bronchodilation and improvement in dyspnea at all timo points, although onset of bronchodilation is slower than with long-acting β2-agonists. Combining these agents has been shown to decrease daytime rescue inhaler use, improve morning and evening peak expiratory flow rates, and improve bronchodilator efficacy compared with monotherapy. Pharmacoeconomic data lend support to the recommendation of tiotropium as a first-line long-acting agent.

Conclusions:

Tiotropium appears to be the best option as a first-line drug for patients with moderate-to-severe COPD because of its ability to sustain bronchodilator effect, improve quality of life, reduce COPD exacerbations, and reduce health resource usage. Patients who remain symptomatic may benefit from the addition of a long-acting β2-agonist to tiotropium monotherapy.

Chronic obstructive pulmonary disease: an evidence-based approach to treatment with a focus on anticholinergic bronchodilation

Chronic obstructive pulmonary disease is a prevalent condition associated with a high societal burden. Despite a decrease in the prevalence of smoking in the United States, the rates of morbidity and mortality associated with chronic obstructive pulmonary disease are expected to continue to increase. Appropriate treatment can have an important impact on many facets of the disease. This article reviews evidence gathered in a PubMed search of papers published from January 1, 2004, to December 31, 2007. The search terms used were chronic obstructive pulmonary disease, epidemiology, practice guidelines, clinical trial, and meta-analysis. Selection of pharmacological therapy is based on severity of disease and differences among the effects of drugs on various end points, including the criterion standard, forced expiratory volume in the first second of expiration. Other important variables, which are closely related to patients' perception of their condition, include reduction in acute exacerbations, improved quality of life, improved exercise performance, and reduced hyperinflation. When maintenance therapy is indicated, clinical evidence suggests initiating treatment with a long-acting agent, either a once-daily anticholinergic or a twice-daily beta2-agonist. If combination therapy is indicated, data support using long-acting drugs from different classes that provide complementary modes of action (beta2-agonist, anticholinergic, inhaled corticosteroid). In this setting, inhaled corticosteroids may further reduce exacerbations when given with a beta2-agonist, an anticholinergic, or both.

Safety, tolerability and risk benefit analysis of tiotropium in COPD

COPD is a chronic disease and, like many other chronic diseases, there is no treatment to reverse the severity of the disease except for lung transplant. To date, no inhaled medications have been shown to improve survival. Tiotropium bromide is a long-acting inhaled anticholinergic drug for the treatment of COPD that can improve lung function, reduce symptoms and exacerbations, and improve quality of life with once-daily dosing. It was initially approved and marketed in several countries in Europe in 2002 and then approved in the US in 2004. Tiotropium is generally well tolerated with dry mouth being the main adverse effect. Other adverse effects include constipation, tachycardia, blurred vision, urinary retention and increased intraocular pressure. Despite the recently raised concerns about an excess risk of cardiovascular adverse events with inhaled anticholinergic agents, the risk/benefit ratio of tiotropium appears still favorable given the favorable safety profile demonstrated in the UPLIFT study. However, caution should be advised in patients at high risk for cardiovascular disease given the paucity of data in such patients.