Incorporating New Evidence on Inhaled Medications in COPD. The Latin American Chest Association (ALAT) 2019

This document on COPD from the Latin American Chest Association (ALAT-2019) uses PICO methodology to analyze new evidence on inhaled medication and answer clinical questions. The following key points emerged from this analysis: 1) evidence is lacking on the comparison of short-acting vs. long-acting bronchodilators in patients with mild COPD; patients with moderate-to-severe COPD obtain greater benefit from long-acting bronchodilators; 2) the benefits of monotherapy with long-acting antimuscarinic agents (LAMA) and combined therapy with long-acting β₂-agonists and inhaled corticosteroids (LABA/ICS) are similar, although the latter is associated with a greater risk of pneumonia; 3) LABA/LAMA offer greater benefits in terms of lung function and risk of exacerbation than LABA/ICS (the latter involve an increased risk of pneumonia), 4) LAMA/LABA/ICS have greater therapeutic benefits than LABA/LAMA on the risk of moderate-severe exacerbations. With regard to the role of eosinophils in guiding the use of ICS, ICS withdrawal must be considered when the initial indication was wrong or no response is elicited, in patients with side effects such as pneumonia, and in patients with a low risk of exacerbation and an eosinophil blood count of <300 cells/μl. All this evidence, categorized according to the severity of the obstruction, symptoms, and risk of exacerbations, has been used to generate an algorithm for the use of inhaled medication in COPD.

ALAT-2014 Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines: questions and answers

ALAT-2014 COPD Clinical Practice Guidelines used clinical questions in PICO format to compile evidence related to risk factors, COPD screening, disease prognosis, treatment and exacerbations. Evidence reveals the existence of risk factors for COPD other than tobacco, as well as gender differences in disease presentation. It shows the benefit of screening in an at-risk population, and the predictive value use of multidimensional prognostic indexes. In stable COPD, similar benefits in dyspnea, pulmonary function and quality of life are achieved with LAMA or LABA long-acting bronchodilators, whereas LAMA is more effective in preventing exacerbations. Dual bronchodilator therapy has more benefits than monotherapy. LAMA and combination LABA/IC are similarly effective, but there is an increased risk of pneumonia with LABA/IC. Data on the efficacy and safety of triple therapy are scarce. Evidence supports influenza vaccination in all patients and anti-pneumococcal vaccination in patients <65years of age and/or with severe airflow limitation. Antibiotic prophylaxis may decrease exacerbation frequency in patients at risk. The use of systemic corticosteroids and antibiotics are justified in exacerbations requiring hospitalization and in some patients managed in an outpatient setting.

Effects of topical instillation of minocycline hydrochloride on cyst size and renal function in polycystic kidney disease

To reduce renal cyst size in autosomal dominant polycystic kidney disease (ADPKD), minocycline hydrochloride solution was instilled into the enlarged cysts in three ADPKD patients. In one patient with reduced renal function, such sclerotherapy apparently diminished cyst size, but without apparent improving effect on renal function at 7 months of follow-up. The second patient, who needed the replacement therapy on admission, had been free from hemodialysis over 4 months after the therapy. Persistent flank pain disappeared in both patients. In the third patient with normal renal function, sclerotherapy was done to get a better control of hypertension. Initially blood pressure decreased, but it returned up to the pre-therapy level irrespective of definite reduction of the enlarged cysts at 8 months of follow-up. The therapy with minocycline hydrochloride did not appear harmful, and may be helpful in the management of ADPKD.

Increased internal calcium mobilization in platelets of patients with chronic renal failure

Platelet free calcium concentrations ([Ca2+]i) were measured with Fura-2 to elucidate the intracellular calcium kinetics in patients with renal disease. There were no significant differences of the resting [Ca2+]i among the control subjects (C) (n = 12), patients with chronic glomerulonephritis (CGN) (n = 8), and patients with chronic renal failure (CRF) (n = 12). In all groups, platelets [Ca2+]i were significantly increased by agonists (thrombin, adenosine diphosphate) compared with their respective basal level. Thrombin-induced [Ca2+]i rise was significantly higher in CRF (840 +/- 265 nM) than in C (600 +/- 163) and CGN (562 +/- 137). Also adenosine diphosphate elicited similar responses. In the presence of calcium chelator in the incubation buffer, the elevation of [Ca2+]i after thrombin stimulation was statistically higher in CRF (469 +/- 85 nM) than in C (275 +/- 60) and CGN (301 +/- 41). These findings suggest that platelets of CRF were capable of increasing [Ca2+]i in response to agonists, through further mobilization of calcium from the intracellular pool rather than the elevation of transmembrane calcium influx.

Reduced glomerular hypertrophy by somatostatin analog, SMS 201-995, in the subtotal nephrectomized rats fed high-protein meals

The chronic effects of SMS 201-995 (SMS), a long-acting somatostatin analog, on the progression of renal failure in 3/4 subtotal nephrectomized rats (NPX) fed high protein meals (40% protein) were investigated. Rats were divided into four groups, [i.e., normal control (C) (n = 6), NPX control (NPX-C) (7), NPX treated with SMS 1.0 micrograms/day (SMS-1.0) (7) and SMS-10.0 (7)]. SMS was continuously administered s.c. via an osmotically driven pump for 8 weeks. SMS had no significant changes in either body weight or hematocrit levels for NPX groups. Systolic blood pressure in NPX rats showed similar elevations, but SMS had no distinct effect on it for them. Significant changes in urine volume, creatinine clearance, and urinary protein excretion were not obtained among the NPX rats. No significant changes of glomerular sclerosis index was found among the NPX rats. Mean planar area of glomeruli in NPX rats was significantly larger than in normal control rats. NPX treated with both 1.0 and 10.0 micrograms/day SMS had statistically smaller values compared with NPX control rats. It was concluded that the chronic administration of SMS reduced glomerular hypertrophy without altering renal functions in this experimental model.

Effect of glucagon infusion on renal hemodynamics in normal subjects and patients with chronic glomerulonephritis

The effect of glucagon infusion (15-20 ng/kg/min, for one hour) on renal hemodynamics was examined in normal subjects and in patients with chronic glomerulonephritis (CGN). In normal subjects, the glomerular filtration rate (GFR) was significantly increased by glucagon with a concomitant rise in effective renal plasma flow (ERPF) and filtration fraction (FF) (GFR/ERPF). In renal patients with a baseline GFR of above 90 ml/min/l/73 m2, GFR was significantly increased in response to glucagon, without a significant rise in ERPF. The patients whose baseline GFR ranged from 40-90 ml/min had no significant increase in GFR, while ERPF rose significantly. These results suggest that the renal hemodynamic response to glucagon infusion were modified by the level of baseline GFR in patients with chronic glomerulonephritis.

Effects of chronic administration of somatostatin analogue SMS 201-995 on the progression of chronic renal failure in subtotal nephrectomized rats

The recent study has demonstrated the presence of somatostatin (SRIF) secretory cells in the rat glomerulus. Because of the polyvalent actions of this peptide, SRIF may play some roles in the evolution of chronic renal failure. The present study evaluated the effects of a long acting SRIF analogue, SMS 201-995 on the progression of renal failure in 3/4 nephrectomized (NPX) rats. Animals were divided into four groups; (1) normal control (C) (n = 9), (2) NPX-C (n = 10), (3) NPX treated with SMS 201-995 (0.5 micrograms/day) (NPX-0.5) (n = 9) and (4) NPX with SMS 201-995 (5.0 micrograms/day) (NPX-5.0) (n = 9). This drug was subcutaneously given daily for 6 weeks. Periodic observations were done at 0, 3 and 6 weeks. Both hematocrit and systolic blood pressure showed significant fall and rise, respectively, in NPX rats compared with C at 3 and 6 weeks. Also both serum creatinine and blood urea nitrogen in these groups elevated significantly at 3 and 6 weeks compared with C. Not significant changes were observed in the 24-h urine volume among the NPX rats. At 6 weeks, the urinary protein excretion in NPX-5.0 was significantly less than those in NPX-C and NPX-0.5 rats. Urinary sodium excretion in NPX-5.0 was significantly lower than that in NPX-C. Histologic examination of the kidney showed less proliferation of mesangial cells in NPX-5.0 than NPX-C. These results suggest that SMS 201-995 may limit the rate of progression of chronic renal failure in this experimental model.