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Pleasants RA, Henderson AG, Bayer V, Shaikh A, Drummond MB. Effect on Physical Position of Peak Inspiratory Flow in Stable COPD: An Observational Study. Chronic Obstr Pulm Dis 2024; 11:174-186. [PMID: 38236166 DOI: 10.15326/jcopdf.2023.0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Background We examined the effect of physical position on peak inspiratory flow (PIF) in patients with chronic obstructive pulmonary disease (COPD) using dry-powder inhalers (DPIs) with low‑medium internal resistance (R2) and/or high internal resistance (R5). Methods This prospective study in stable, ambulatory patients with spirometry-confirmed COPD evaluated the effect of 3 physical positions on maximal PIF achieved. Participants had PIFs of 30-90L/min (R5) or 60-90L/min (R2 DPIs) using the In-Check™ DIAL. PIF was measured in triplicate randomly in 3 positions that patients might be in while using their inhaler (standing, sitting, and semi-upright [supine position with the head of the bed at 45°, neck flexed forward]) against prescribed DPI resistance (R2/R5/both). Correlations between PIF and percentage decline in PIF between positions and differences in participant characteristics with >10% versus ≤10% PIF decline standing to semi-upright were calculated. Results A total of 76 participants (mean age, 65.2 years) had positional measurements; 59% reported seated DPI use at home. The mean (standard deviation) PIF standing, sitting, and semi-upright was 80.7 (13.4), 77.8 (14.3), and 74.0 (14.5) L/min, respectively, for R2 and 51.1 (9.52), 48.6 (9.84), and 45.8 (7.69) L/min, respectively, for R5 DPIs. PIF semi-upright was significantly lower than sitting and standing (R2; P < 0.0001) and standing (R5; P= 0.002). Approximately half of the participants had >10% decline in PIF from standing to semi-upright. Patient characteristics exceeding the 0.10 absolute standardized difference threshold with the decline in PIF for both the R2 and R5 DPIs were waist-to-hip ratio, modified Medical Research Council dyspnea score, and postbronchodilator percentage predicted forced vital capacity and PIF by spirometry. Conclusions PIF was significantly affected by physical position regardless of DPI resistance. PIF was highest when standing and lowest when semi-upright. We recommend that patients with COPD stand while using an R2 or R5 DPI. Where unfeasible, the position should be sitting rather than semi-upright. ClinicalTrials.gov identifier NCT04168775.
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Affiliation(s)
- Roy A Pleasants
- Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Ashley G Henderson
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Valentina Bayer
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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Pleasants RA, Donohue JF. Current Perspectives of Pharmacotherapies for COPD. Respir Care 2023; 68:927-938. [PMID: 37353337 PMCID: PMC10289617 DOI: 10.4187/respcare.10952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Pharmacotherapies and avoidance of environmental/inhaled toxins are core to managing COPD. Compared to the drugs available 50 years ago, there has been substantial progress with COPD pharmacotherapies, but gaps in adherence and inhaler use persist. Personalizing inhaled pharmacotherapies is now possible with digital technologies by objectively documenting adherence and guiding inhaler technique. Another means to improve existing pharmacotherapies is through phenotyping and biomarkers. This is especially important considering the heterogeneity of the disease COPD. Blood eosinophils are now a recommended biomarker to guide use of inhaled corticosteroids and biologics in COPD. On the near horizon, we will see new inhaled medications as dual phosphodiesterase inhibitors, drugs to treat basic protein abnormalities as in alpha-1 antitrypsin deficiency that could have remarkable benefits, and biologic drugs targeting specific cell/mediator types in the COPD population. Characterization of COPD phenotypes, as asthma/COPD overlap and comorbid heart disease are vital to understand how to optimize pharmacotherapies. Importantly, we must determine how to optimize current medications; otherwise, we will repeat the same mistakes with new medications. But as we know so well, as we peel one layer of complexity, we encounter many more questions, all the while dedicated to limiting the burden of COPD.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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3
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Pleasants RA, Chan AH, Mosnaim G, Costello RW, Dhand R, Schworer SA, Merchant R, Tilley SL. Integrating digital inhalers into clinical care of patients with asthma and chronic obstructive pulmonary disease. Respir Med 2022; 205:107038. [PMID: 36446239 DOI: 10.1016/j.rmed.2022.107038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/21/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
Modernizing inhaled medications through digital technology can help address persistent problems of non-adherence and poor inhaler technique in patients with obstructive lung diseases. With a growing body of supportive clinical studies, advances in digital inhaler sensors and platforms, greater support from payers and healthcare organizations, significant growth with these technologies is expected. While all digital (smart) inhalers record adherence, these are distinguished by their compatibility with commercial inhalers, capabilities to guide inhaler technique, use of patient-reported outcomes, and user-friendliness for both the healthcare professional (HCP) and patient. Due to the complexity and novelty of employing digital inhalers, collaboration with multiple entities within health systems is necessary and a well-planned integration is needed. For HCPs and patients, cybersecurity and privacy are critical, it will require review by each healthcare organization. In the US, some payers reimburse for remote monitoring using digital inhalers, but reimbursement is currently unavailable in other countries. There are several models for remote patient care, as employing an active, ongoing digital interface between the HCP and patient or they may choose to only review data at clinical encounters. Personalization of therapies and feedback are key to success. While digital inhaler malfunction uncommonly occurs, patient attrition over a year is significant. Some patients will be challenged to use digital platforms or have the necessary technology. Additional research is needed to address cost-effectiveness, in vivo accuracy of inspiratory measurement capable devices, ability to teach inhaler technique, their application for monitoring lung function, and lastly real-world adoption and implementation in routine clinical practice.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Amy Hy Chan
- Faculty of Medical and Health Sciences, University of Auckland, USA.
| | - Giselle Mosnaim
- NorthShore University Health System, Clinical Associate Professor at the University of Chicago Pritzker School of Medicine, USA.
| | - Richard W Costello
- Royal College of Surgeons Ireland, 123 St Stephen's Green, Dublin 2, D02 YN77, Ireland.
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
| | - Stephen A Schworer
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | - Rajan Merchant
- Woodland Clinic Medical Group, Dignity Health Medical Foundation, CommonSpirit Health Research Institute, CommonSpirit Health Dignity Health, Woodland Clinic, 632 W Gibson Rd, Woodland, CA, USA.
| | - Stephen L Tilley
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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4
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Pleasants RA, Bedoya AD, Boggan JM, Welty-Wolf K, Tighe RM. The Eyes Have It-for Idiopathic Pulmonary Fibrosis: a Preliminary Observation. Pulm Ther 2022; 8:327-331. [PMID: 35927537 PMCID: PMC9458811 DOI: 10.1007/s41030-022-00198-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/21/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The disease origins of idiopathic pulmonary fibrosis (IPF), which occurs at higher rates in certain races/ethnicities, are not understood. The highest rates occur in white persons of European descent, particularly those with light skin, who are also susceptible to lysosomal organelle dysfunction of the skin leading to fibroproliferative disease . We had observed clinically that the vast majority of patients with IPF had light-colored eyes, suggesting a phenotypic characteristic. Methods We pursued this observation through a research database from the USA Veterans Administration, a population that has a high occurrence of IPF due to predominance of elderly male smokers. Using this medical records database, which included facial photos, we compared the frequency of light (blue, green, hazel) and dark (light brown, brown) eyes among white patients diagnosed with IPF compared with a control group of lung granuloma only (no other radiologic evidence of interstitial lung disease). Results Light eye color was significantly more prevalent in patients with IPF than in the control group with lung granuloma [114/147 (77.6%) versus 129/263 (49.0%], p < 0.001), indicating that light-colored eyes are a phenotype associated with IPF . Conclusion We provide evidence that light eye color is predominant among white persons with IPF.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, 7202 Marsico Hall, 125 Mason Farm Rd, Chapel Hill, NC, USA. .,Durham VA Medical Center, Durham, NC, USA.
| | - Armando D Bedoya
- Duke University School of Medicine and Department of Biostatistics and Bioinformatiics, Durham, NC, USA
| | - Joel M Boggan
- Department of Medicine, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Karen Welty-Wolf
- Duke University School of Medicine, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Robert M Tighe
- Duke University School of Medicine, Durham Veterans Affairs Healthcare System, Durham, NC, USA
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Ohar JA, Ferguson GT, Mahler DA, Drummond MB, Dhand R, Pleasants RA, Anzueto A, Halpin DMG, Price DB, Drescher GS, Hoy HM, Haughney J, Hess MW, Usmani OS. Measuring Peak Inspiratory Flow in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2022; 17:79-92. [PMID: 35023914 PMCID: PMC8747625 DOI: 10.2147/copd.s319511] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Dry powder inhalers (DPIs) are breath actuated, and patients using DPIs need to generate an optimal inspiratory flow during the inhalation maneuver for effective drug delivery to the lungs. However, practical and standardized recommendations for measuring peak inspiratory flow (PIF)—a potential indicator for effective DPI use in chronic obstructive pulmonary disease (COPD)—are lacking. To evaluate recommended PIF assessment approaches, we reviewed the Instructions for Use of the In-Check™ DIAL and the prescribing information for eight DPIs approved for use in the treatment of COPD in the United States. To evaluate applied PIF assessment approaches, we conducted a PubMed search from inception to August 31, 2021, for reports of clinical and real-life studies where PIF was measured using the In-Check™ DIAL or through a DPI in patients with COPD. Evaluation of collective sources, including 47 applicable studies, showed that instructions related to the positioning of the patient with their DPI, instructions for exhalation before the inhalation maneuver, the inhalation maneuver itself, and post-inhalation breath-hold times varied, and in many instances, appeared vague and/or incomplete. We observed considerable variation in how PIF was measured in clinical and real-life studies, underscoring the need for a standardized method of PIF measurement. Standardization of technique will facilitate comparisons among studies. Based on these findings and our clinical and research experience, we propose specific recommendations for PIF measurement to standardize the process and better ensure accurate and reliable PIF values in clinical trials and in daily clinical practice.
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Affiliation(s)
- Jill A Ohar
- Section of Pulmonary, Critical Care, Allergy, and Immunology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | | | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Quality, University of Michigan, Ann Arbor, MI, USA
| | - Antonio Anzueto
- Pulmonology Section, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - David B Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Observational and Pragmatic Research Institute, Singapore
| | - Gail S Drescher
- Pulmonary Services Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - Haley M Hoy
- Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John Haughney
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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6
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Chan AHY, Pleasants RA, Dhand R, Tilley SL, Schworer SA, Costello RW, Merchant R. Digital Inhalers for Asthma or Chronic Obstructive Pulmonary Disease: A Scientific Perspective. Pulm Ther 2021; 7:345-376. [PMID: 34379316 PMCID: PMC8589868 DOI: 10.1007/s41030-021-00167-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022] Open
Abstract
Impressive advances in inhalation therapy for patients with asthma and chronic obstructive pulmonary disease (COPD) have occurred in recent years. However, important gaps in care remain, particularly relating to poor adherence to inhaled therapies. Digital inhaler health platforms which incorporate digital inhalers to monitor time and date of dosing are an effective disease and medication management tool, promoting collaborative care between clinicians and patients, and providing more in-depth understanding of actual inhaler use. With advances in technology, nearly all inhalers can be digitalized with add-on or embedded sensors to record and transmit data quantitating inhaler actuations, and some have additional capabilities to evaluate inhaler technique. In addition to providing an objective and readily available measure of adherence, they allow patients to interact with the device directly or through their self-management smartphone application such as via alerts and recording of health status. Clinicians can access these data remotely and during patient encounters, to better inform them about disease status and medication adherence and inhaler technique. The ability for remote patient monitoring is accelerating interest in and the use of these devices in clinical practice and research settings. More than 20 clinical studies of digital inhalers in asthma or COPD collectively show improvement in medication adherence, exacerbation risk, and patient outcomes with digital inhalers. These studies support previous findings about patient inhaler use and behaviors, but with greater granularity, and reveal some new findings about patient medication-taking behaviors. Digital devices that record inspiratory flows with inhaler use can guide proper inhaler technique and may prove to be a clinically useful lung function measure. Adoption of digital inhalers into practice is still early, and additional research is needed to determine patient and clinician acceptability, the appropriate place of these devices in the therapeutic regimen, and their cost effectiveness. Video: Digital Inhalers for Asthma or Chronic Obstructive Pulmonary Disease: A Scientific Perspective (MP4 74535 kb)
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Affiliation(s)
- Amy H. Y. Chan
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1023 New Zealand
| | - Roy A. Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN USA
| | - Stephen L. Tilley
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Stephen A. Schworer
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Richard W. Costello
- Royal College of Surgeons Ireland, 123 St Stephen’s Green, Dublin 2, D02 YN77 Ireland
| | - Rajan Merchant
- Dignity Health Woodland Clinic, 632 W Gibson Rd, Woodland, CA USA
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7
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Strange C, Richard CL, Shan S, Phillips BA, Kanotra S, Drummond MB, Megenhardt L, Lal C, Pleasants RA. A population-based estimate of the health care burden of obstructive sleep apnea using a STOP-BAG questionnaire in South Carolina. J Clin Sleep Med 2021; 17:367-374. [PMID: 33089773 DOI: 10.5664/jcsm.8860] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Population based estimates of obstructive sleep apnea (OSA) frequency and health impact are incomplete. The aim of this study was to determine the prevalence of risk factors for physician and sleep study diagnosed OSA among individuals in a state-based surveillance program. METHODS Using questions inserted into the 2016 (n = 5,564) and 2017 (n = 10,884) South Carolina Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention, we analyzed the prevalence of physician diagnosed OSA and associated comorbidities. The validated STOP-BANG questionnaire without neck circumference (STOP-BAG) defined populations at moderate risk (score 3-4) and high risk (score 5-7). Statistical analysis using weighted prevalence and means and their 95% confidence intervals (CI) thus reflect population estimates of disease burden. RESULTS The population-based prevalence of physician diagnosed OSA in South Carolina was 9.7% (95% CI: 9.0-10.4). However, the populations with moderate risk (18.5%, 95% CI: 17.3-19.8) and high risk (25.5%, 95% CI: 23.9-27.1) for OSA, as determined by the STOP-BAG questionnaire, were much higher. Compared to those at low risk for OSA, those at high risk were more often diagnosed with coronary heart disease, stroke, asthma, skin cancer, other cancers, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, and diabetes (all P < .001). CONCLUSIONS OSA is common and strongly associated with major comorbidities. As such, this public health crisis warrants more diagnostic and therapeutic attention. The STOP-BAG questionnaire provides a public health platform to monitor this disease.
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Affiliation(s)
- Charlie Strange
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Chelsea L Richard
- South Carolina Department of Health and Environmental Control, Columbia, South Carolina
| | | | - Barbara A Phillips
- Division of Pulmonary Medicine, University of Kentucky, Lexington, Kentucky
| | - Sarojini Kanotra
- Division of Pulmonary Medicine, University of Kentucky, Lexington, Kentucky.,Kentucky Department for Public Health, Frankfort, Kentucky
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Chitra Lal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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8
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Bedoya A, Pleasants RA, Boggan JC, Seaman D, Reihman A, Howard L, Kundich R, Welty-Wolf K, Tighe RM. Interstitial lung disease in a veterans affairs regional network; a retrospective cohort study. PLoS One 2021; 16:e0247316. [PMID: 33735247 PMCID: PMC7971476 DOI: 10.1371/journal.pone.0247316] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
Background The epidemiology of Interstitial Lung Diseases (ILD) in the Veterans Health Administration (VHA) is presently unknown. Research question Describe the incidence/prevalence, clinical characteristics, and outcomes of ILD patients within the Veteran’s Administration Mid-Atlantic Health Care Network (VISN6). Study design and methods A multi-center retrospective cohort study was performed of veterans receiving hospital or outpatient ILD care from January 1, 2008 to December 31st, 2015 in six VISN6 facilities. Patients were identified by at least one visit encounter with a 515, 516, or other ILD ICD-9 code. Demographic and clinical characteristics were summarized using median, 25th and 75th percentile for continuous variables and count/percentage for categorical variables. Characteristics and incidence/prevalence rates were summarized, and stratified by ILD ICD-9 code. Kaplan Meier curves were generated to define overall survival. Results 3293 subjects met the inclusion criteria. 879 subjects (26%) had no evidence of ILD following manual medical record review. Overall estimated prevalence in verified ILD subjects was 256 per 100,000 people with a mean incidence across the years of 70 per 100,000 person-years (0.07%). The prevalence and mean incidence when focusing on people with an ILD diagnostic code who had a HRCT scan or a bronchoscopic or surgical lung biopsy was 237 per 100,000 people (0.237%) and 63 per 100,000 person-years respectively (0.063%). The median survival was 76.9 months for 515 codes, 103.4 months for 516 codes, and 83.6 months for 516.31. Interpretation This retrospective cohort study defines high ILD incidence/prevalence within the VA. Therefore, ILD is an important VA health concern.
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Affiliation(s)
- Armando Bedoya
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Roy A. Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Joel C. Boggan
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Durham VA Medical Center, Durham, North Carolina, United States of America
| | - Danielle Seaman
- Department of Radiology, Durham VA Medical Center, Durham, North Carolina, United States of America
| | - Anne Reihman
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Lauren Howard
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, United States of America
| | - Robert Kundich
- Department of Medicine, Durham VA Medical Center, Durham, North Carolina, United States of America
| | - Karen Welty-Wolf
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Durham VA Medical Center, Durham, North Carolina, United States of America
| | - Robert M. Tighe
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Durham VA Medical Center, Durham, North Carolina, United States of America
- * E-mail:
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Gao J, Li L, Jiang N, Liao Y, Kong L, Song Y, Xu J, Cao J, Li Y, Que C, Pleasants RA. Effect of OM-85 BV on reducing bronchiectasis exacerbation in Chinese patients: the iPROBE study. J Thorac Dis 2021; 13:1641-1651. [PMID: 33841955 PMCID: PMC8024857 DOI: 10.21037/jtd-20-1662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Bronchiectasis is characterized by recurrent infectious exacerbations. No existing data inform preventive strategy for exacerbations beyond chronic macrolides. OM-85 BV, an immunostimulant, has been shown to prevent recurrent respiratory infections. We initiated this 1-year, multi-centered, double-blind, and controlled trial to investigate the PReventive effect of OM-85 BV on Bronchiectasis Exacerbations in Chinese patients (iPROBE). Methods Patients with bronchiectasis aged 18 to 75 years, having at least one exacerbation in the past year, were randomized to receive, in addition to any respiratory medications, two courses of 7 mg of OM-85 BV or matching placebo (one capsule orally per day for 10 days a month) for 3 consecutive months, followed by 3 months without treatment. The primary outcomes included the number of acute infectious exacerbations and the time to first exacerbation. Secondary endpoints included patient-reported respiratory outcomes. Safety measures were also assessed. Results Among the 196 participants, 99 were in the OM-85 BV group and 97 in the placebo group. At week 52, the mean number of acute exacerbations per patient was equal to 0.98 and 0.75, respectively, in the two groups (P=0.14). Difference in the time to first pulmonary exacerbation was not statistically significant (P=0.11). There was no statistically significant difference in any secondary end-points. The safety profile in the two arms was good and the majority of adverse events were mild. Conclusions OM-85 BV did not demonstrate protection in decreasing pulmonary exacerbations of bronchiectasis in this trial performed in Chinese patients. It had good safety profile.
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Affiliation(s)
- Jinming Gao
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lun Li
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Jiang
- Department of Medicine, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Liao
- Department of Medicine, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lingfei Kong
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yuanlin Song
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinfu Xu
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Jie Cao
- Department of Pulmonary and Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuping Li
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chengli Que
- Department of Pulmonary and Critical Care Medicine, First Hospital of Peking University, Beijing, China
| | - Roy A Pleasants
- Division of Pulmonary Medicine and Critical Care, Chapel Hill, NC, USA
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10
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Pleasants RA, Tilley SL, Hickey AJ, Usmani OS. User-life of ICS/LABA inhaler devices should be considered when prescribed as relievers. Eur Respir J 2021; 57:57/1/2003921. [PMID: 33446577 DOI: 10.1183/13993003.03921-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/16/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Roy A Pleasants
- University of North Carolina at Chapel Hill, Division of Pulmonary Diseases and Critical Care Medicine, Chapel Hill, NC, USA
| | - Stephen L Tilley
- University of North Carolina at Chapel Hill, Division of Pulmonary Diseases and Critical Care Medicine, Chapel Hill, NC, USA
| | - Anthony J Hickey
- RTI International, Engineered Systems, Research Triangle Park, NC, USA.,University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Omar S Usmani
- Imperial College London and Royal Brompton Hospital, National Heart and Lung Institute, London, UK
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11
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Pleasants RA, Rivera MP, Tilley SL, Bhatt SP. Both Duration and Pack-Years of Tobacco Smoking Should Be Used for Clinical Practice and Research. Ann Am Thorac Soc 2020; 17:804-806. [PMID: 32348693 PMCID: PMC7405110 DOI: 10.1513/annalsats.202002-133vp] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/29/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Roy A. Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- North Carolina Thoracic Society, Chapel Hill, North Carolina; and
| | - M. Patricia Rivera
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephen L. Tilley
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Surya P. Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Chen K, Pleasants KA, Pleasants RA, Beiko T, Washburn RG, Yu Z, Zhai S, Drummond MB. A Systematic Review and Meta-Analysis of Sputum Purulence to Predict Bacterial Infection in COPD Exacerbations. COPD 2020; 17:311-317. [PMID: 32456479 DOI: 10.1080/15412555.2020.1766433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The 2020 Global Initiative for Obstructive Lung Disease (GOLD) Report highlights the importance of sputum purulence in the decision to prescribe antibiotics for acute exacerbations. The purpose of this systematic review and meta-analysis was to evaluate the strength of literature supporting inclusion of sputum purulence in criteria utilized to evaluate if antimicrobials are indicated in acute COPD exacerbation. A total of 6 observational studies met inclusion criteria for this meta-analysis. Sputum purulence was defined by visual assessment of color, either subjectively by providers and/or patients or by a colored chart, where green or yellow sputum was considered purulent. Four of the studies were primarily conducted in hospitalized patients, one in the emergency department, and one in the primary care setting. Five studies relied upon expectorated sputum and one used bronchoscopy to obtain sputum samples for bacterial cultures. Compared with mucoid sputum, purulent sputum had a significantly higher probability of positive bacterial culture results (RR = 2.14, 95%CI [1.25, 3.67], p = 0.006, moderate quality). For sensitivity analysis, after removal of studies losing 2 or more points from the New Castle-Ottawa scale, the effect value remained statistically significant. This systematic review and meta-analysis showed a moderate level of evidence that purulent sputum during COPD exacerbation, as defined by yellow or green color, is associated with a significantly higher probability of potentially pathogenic bacteria, supporting GOLD report and NICE recommendations.
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Affiliation(s)
- Ken Chen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Roy A Pleasants
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Tatsiana Beiko
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ronald G Washburn
- Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | - Zhiheng Yu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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13
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Ghosh S, Pleasants RA, Ohar JA, Donohue JF, Drummond MB. Prevalence and factors associated with suboptimal peak inspiratory flow rates in COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:585-595. [PMID: 30880948 PMCID: PMC6402615 DOI: 10.2147/copd.s195438] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Adequate peak inspiratory flow rate (PIFR) is required for drug dispersion with dry powder inhalers (DPIs). Prevalence of PIFR discordance (suboptimal PIFR with prescribed inhalers) and factors influencing device-specific PIFR are unclear in COPD. The objective of this study was to determine the prevalence of PIFR discordance and associated clinical factors in a stable COPD population. Patients and methods An observational, single-center, cohort study was conducted including 66 outpatients with COPD. PIFR was measured using the In-Check™ Dial with applied resistance of prescribed inhalers. Participants were defined as discordant if measured PIFR was <30 L/min and <60 L/min for high and low–medium resistance devices, respectively, using an inspiratory effort the participant normally used with their prescribed DPI. Results The median age of the COPD participants was 69.4 years, 92% were white and 47% were female. A total of 48% were using low–medium resistance DPIs (Diskus®/Ellipta®) and 76% used high-resistance DPI (Handihaler®). A total of 40% of COPD participants were discordant to prescribed inhalers. Female gender was the only factor consistently associated with lower PIFR. Shorter height was associated with reduced PIFR for low–medium resistance (r=0.44; P=0.01), but not high resistance (r=0.20; P=0.16). There was no correlation between PIFR by In-Check™ dial and PIFR measured by standard spirometer. Conclusion PIFR is reduced in stable COPD patients, with female gender being the only factor consistently associated with reduced PIFR. Discordance with prescribed inhalers was seen in 40% of COPD patients, suggesting that many COPD patients do not generate adequate inspiratory force to overcome prescribed DPIs resistance in the course of normal use.
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Affiliation(s)
- Sohini Ghosh
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
| | | | - Jill A Ohar
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy, and Immunology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
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Pleasants RA, Heidari K, Ohar J, Donohue JF, Lugogo N, Richard CL, Kanotra S, Mannino DM, Kraft M, Liao W, Strange C. Use of a Cross-Sectional Survey in the Adult Population to Characterize Persons at High-Risk for Chronic Obstructive Pulmonary Disease. Healthcare (Basel) 2019; 7:E12. [PMID: 30669305 PMCID: PMC6473439 DOI: 10.3390/healthcare7010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/02/2019] [Accepted: 01/15/2019] [Indexed: 11/16/2022] Open
Abstract
Rationale/Objective: The Behavioral Risk Factor Surveillance System (BRFSS) health survey has been used to describe the epidemiology of chronic obstructive pulmonary disease (COPD) in the US. Through addressing respiratory symptoms and tobacco use, it could also be used to characterize COPD risk. METHODS Four US states added questions to the 2015 BRFSS regarding productive cough, shortness of breath, dyspnea on exertion, and tobacco duration. We determined COPD risk categories: provider-diagnosed COPD as self-report, high-risk for COPD as ≥10 years tobacco smoking and at least one significant respiratory symptom, and low risk was neither diagnosed COPD nor high risk. Disease burden was defined by respiratory symptoms and health impairments. Data were analyzed using multiple logistic regression models with age as a covariate. RESULTS Among 35,722 adults ≥18 years, the overall prevalence of COPD and high-risk for COPD were 6.6% and 5.1%. Differences among COPD risk groups were evident based on gender, race, age, geography, tobacco use, health impairments, and respiratory symptoms. Risk for disease was seen early where 3.75% of 25⁻34 years-old met high-risk criteria. Longer tobacco duration was associated with an increased prevalence of COPD, particularly >20 years. Seventy-nine percent of persons ≥45 years-old with frequent shortness of breath (SOB) reported having or being at risk of COPD, reflecting disease burden. CONCLUSION These data, representing nearly 18% of US adults, indicates those at high risk for COPD share many, but not all of the characteristics of persons diagnosed with the disease and demonstrates the value of the BRFSS as a tool to define lung health at a population level.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
- Durham VA Medical Center, Durham, NC 27708, USA.
| | - Khosrow Heidari
- South Carolina Department of Health and Environmental Control, Columbia, SC 29201, USA.
| | - Jill Ohar
- Pulmonary, Critical Care, Allergy, Immunologic Diseases Section, Wake Forest University, Winston-Salem, NC 27109, USA.
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Njira Lugogo
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Chelsea L Richard
- South Carolina Department of Health and Environmental Control, Columbia, SC 29201, USA.
| | - Sarojina Kanotra
- Kentucky Department for Public Health, State Public Health Agency, Frankfort, KY 40621, USA.
| | - David M Mannino
- Department of Medicine, University of Kentucky, Lexington, KY 40506, USA.
- GlaxoSmithKline PLC, Philadelphia, PA 19112, USA.
| | - Monica Kraft
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA.
| | - Winston Liao
- Independent Researcher, Chapel Hill, NC 27599, USA.
| | - Charlie Strange
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
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Abstract
Although inhaled therapies are typically preferred for the maintenance treatment of obstructive lung diseases, oral drug therapies can also play valuable roles. The most commonly used oral agents are phosphodiesterase inhibitors, theophylline, macrolides, leukotriene modifiers, and mucoactive agents. Advantages of these oral agents include the unique pharmacologic mechanisms of action, the avoidance of the challenges of proper inhalational lung administration, and, in most instances, relative drug cost. For many of these agents, anti-inflammatory or immunomodulatory effects are the predominant pharmacologic mechanism that each provides clinical benefit, with the exception of guaifenesin. In addition, theophylline, leukotriene modifiers, chronic macrolides, phosphodiesterase inhibitors, and N-acetylcysteine have been shown to decrease exacerbations in obstructive lung disease. Fairly rapid bronchodilation occurs with the phosphodiesterase inhibitors, theophylline, and leukotriene modifiers, although less than that achieved with inhaled therapies. The clinical roles of phosphodiesterase inhibitors, specifically roflumilast, and macrolides continues to be defined today, whereas the roles theophylline and leukotriene modifiers have probably been largely delineated. Azithromycin is the principal macrolide used chronically for obstructive lung diseases, especially COPD. Although guaifenesin is used widely, its effectiveness is unclear, whereas N-acetylcysteine currently has strong evidence supporting a decreased risk of COPD exacerbations. Mucolytic agents like N-acetylcysteine are used more widely outside the United States in obstructive lung diseases.
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Affiliation(s)
- Roy A Pleasants
- Pulmonary Department, Duke Clinical Research Institute, Durham Veterans Administration Hospital, Durham, North Carolina.
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16
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Abstract
Drug delivery by inhalation is the principal strategy to treat obstructive lung diseases, which affect about 15% of the population in the United States. Aerosol delivery devices have evolved over more than 60 years from the basic pressurized metered-dose inhaler and nebulizer to numerous types of inhalers and devices, including valved holder chambers, dry powder inhalers, soft mist inhalers, as well as smart inhalers and nebulizers. Although these devices improve a patient's ability to self-administer medication, many problems with optimal delivery still exist. Appropriate selection and repeated patient education can help lessen the problems with these devices. Aerosol science is evolving, with methods of measurement that include radio-scintigraphy and magnetic resonance imaging, to provide a better understanding of aerosol delivery and effects. Understanding the science and clinical application of aerosol drug delivery can substantially aid clinicians in optimizing these therapies for their patients.
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Affiliation(s)
- Roy A Pleasants
- Duke Clinical Research Institute and Durham Veterans Administration Pulmonary Division, Durham, North Carolina
| | - Dean R Hess
- Massachusetts General Hospital, Harvard Medical School, and Northeastern University in Boston, Massachusetts. He is also Managing Editor of Respiratory Care.
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Pleasants RA, Wang T, Xu X, Beiko T, Bei H, Zhai S, Drummond MB. Nebulized Corticosteroids in the Treatment of COPD Exacerbations: Systematic Review, Meta-Analysis, and Clinical Perspective. Respir Care 2018; 63:1302-1310. [PMID: 30237276 DOI: 10.4187/respcare.06384] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND COPD guidelines report that systemic corticosteroids are preferred over inhaled corticosteroids in the treatment of exacerbations, but the inhaled route is considered to be an option. OBJECTIVES To conduct a systematic review and meta-analysis regarding the efficacy and safety of inhaled corticosteroids for COPD exacerbations. The second objective was to provide pharmacologic and clinical perspectives of inhaled corticosteroids for COPD exacerbations. METHODS The primary outcome was a change in FEV1 baseline versus the last measured value. Secondary outcomes were a change in (PaO2 ) and (PaCO2 ) baselines versus the last measured values; FEV1, PaO2 , and PaCO2 at 24 or 72 h; and hyperglycemia. RESULTS Each of the 9 studies included in the meta-analysis was conducted in subjects who were hospitalized and not critically ill. Our meta-analysis indicated that high-dose nebulized budesonide 4-8 mg/d was noninferior to systemic corticosteroids on the change in FEV1 between baseline and the last measured value (mean difference of 0.05, 95% CI -0.01 to 0.12, P = .13) and PaCO2 (mean difference of -1.14, 95% CI -2.56 to 0.27, P = .11) but of inferior efficacy for PaO2 changes (mean difference of -1.46, 95% -2.75 to -0.16, P = .03). Hyperglycemia was less frequent with high-dose nebulized budesonide (risk ratio, 0.13; 95% CI 0.03-0.46; P = .002). CONCLUSIONS Based on our meta-analysis with a change in FEV1 as the primary end point, high-dose nebulized budesonide was an acceptable alternative to systemic corticosteroids in hospitalized subjects with COPD exacerbations who were not critically ill. Additional well-designed prospective studies are needed in both the acute care and ambulatory settings. We provide perspective on how this evidence might be applied in clinical practice.
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Affiliation(s)
- Roy A Pleasants
- Duke Clinical Research Institute, Durham, NC Pulmonary Department, and Durham VA Medical Center, Durham, North Carolina.
| | - Tiansheng Wang
- Chapel Hill School of Public Health, Chapel Hill, North Carolina
| | - Xiaohan Xu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Tatsiana Beiko
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - He Bei
- Pulmonary Division, Third Hospital, Peking University Medical University, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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18
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Pleasants RA. Glycopyrrolate/eFlow CS: The First Nebulized Long-Acting Muscarinic Antagonist Approved to Treat Chronic Obstructive Pulmonary Disease. Ann Pharmacother 2018; 53:285-293. [PMID: 30175596 PMCID: PMC6357169 DOI: 10.1177/1060028018798753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Objective: To review the pharmacology, efficacy, and safety of the first nebulized long-acting muscarinic antagonist (LAMA), glycopyrrolate (GLY)/eFlow closed system (CS) nebulizer, approved for maintenance treatment of chronic obstructive pulmonary disease (COPD). Data Sources: A PubMed search was conducted (January 2000 to July 2018) using the following terms/phrases: nebulized glycopyrrolate, inhalation devices in COPD, long-acting muscarinic antagonists COPD, and COPD survey. Retrieved articles were reviewed to identify additional references. Study Selection and Data Extraction: Primary and review articles on GLY/eFlow CS and other treatment options for patients with COPD were selected. Data Synthesis: Guidelines recommend the use of LAMAs, alone or in combination with long-acting β2-agonists, as maintenance therapy for the majority of patients with COPD. With the range of different devices and bronchodilators now available, treatment can be tailored based on individual needs. The eFlow CS nebulizer delivers GLY rapidly over a 2- to 3-minute period and provides bronchodilation within 30 minutes, lasting 12 hours. Phase 2 dose-finding and phase 3 studies demonstrated sustained statistically significant and clinically important improvements in pulmonary function and patient-reported outcomes with GLY/eFlow CS. Relevance to Patient Care and Clinical Practice: GLY/eFlow CS provides a novel, portable, efficient, and rapid drug delivery system. Conclusions: The recently approved GLY/eFlow CS drug-device combination provides a viable treatment option for patients with COPD, particularly those with conditions that may impair proper use of traditional handheld inhalers.
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Affiliation(s)
- Roy A Pleasants
- 1 Duke Clinical Research Institute and Durham Veterans Administration Medical Center, Durham, NC, USA
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19
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Abstract
The novel, easy-to-use, breath-actuated fluticasone propionate/salmeterol multidose dry powder inhaler (MDPI) (AirDuo RespiClick®) was recently approved in the USA for twice-daily treatment of asthma in patients aged ≥ 12 years. This inhaled corticosteroid (ICS) and long-acting β2-adrenoreceptor agonist (LABA) combination treatment is available in low-, mid- and high-dosage formulations (55/14, 113/14 and 232/14 μg, respectively). In 12-week, phase III trials in patients aged ≥ 12 years with persistent asthma, all three dosages of fluticasone propionate/salmeterol MDPI treatment produced significant improvements in lung function and other asthma symptoms compared with fluticasone propionate MDPI monotherapy or placebo MDPI. In a 26-week, phase III trial in this patient population, mid- and high-dosage fluticasone propionate/salmeterol MDPI were noninferior to mid- (250/50 μg) and high- (500/50 μg) dosage fluticasone propionate/salmeterol DPI (Advair Diskus®), respectively, in terms of improvements in lung function. Treatment-emergent adverse events (TEAEs) with fluticasone propionate/salmeterol MDPI were mostly of mild to moderate severity, with no severe TEAEs deemed to be treatment related. Although long-term pharmacovigilance is required to fully establish its safety, given the ease of use and favorable characteristics of the device and its clinical efficacy at relatively low metered doses of the active moieties, fluticasone propionate/salmeterol MDPI is an important emerging treatment option in patients aged ≥ 12 years with asthma.
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Affiliation(s)
- Julia Paik
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Lesley J Scott
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
| | - Roy A Pleasants
- Duke Clinical Research Institute and Durham Veterans Administration Medical Center, Durham, NC, USA
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Xing Y, Zhang H, Sun S, Ma X, Pleasants RA, Tang H, Zheng H, Zhai S, Wang T. Clinical features and treatment of pediatric patients with drug-induced anaphylaxis: a study based on pharmacovigilance data. Eur J Pediatr 2018; 177:145-154. [PMID: 29168013 PMCID: PMC5748398 DOI: 10.1007/s00431-017-3048-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/09/2017] [Accepted: 11/09/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED We assessed the clinical features and treatment of pediatric patients with drug-induced anaphylaxis in clinical settings. Pediatric drug-induced anaphylaxis cases collected by the Beijing Pharmacovigilance Database from 2004 to 2014 were analyzed. A total of 91 cases were identified. Drug-induced anaphylaxis was primarily caused by antibiotics (53%). Children of 0-5 years were more likely to develop cyanosis symptoms than children of 13-17 years (OR = 5.14, 95%CI [1.74, 15.20], P = 0.002). Children of 13-17 years were more likely to develop hypotension than children of 6-12 years (OR = 11.79, 95%CI [2.28, 60.87], P = 0.002), and to manifest both neurological symptoms (OR = 3.56, 95%CI [1.26, 10.08], P = 0.015) and severe anaphylaxis than children of 0-5 years (OR = 15.46, 95%CI [1.85, 129.33], P = 0.002). Supratherapeutic doses of epinephrine were more likely with intravenous (IV) bolus (92%) in contrast to either intramuscular (IM) (36%, OR = 19.25, 95%CI [1.77, 209.55], P = 0.009) or subcutaneous (SC) injections (36%, OR = 19.80, 95% CI [1.94, 201.63], P = 0.005). Only 62 (68%) patients received epinephrine treatment as the first-line therapy. CONCLUSION This study demonstrates that antibiotics were the most common cause of pediatric drug-induced anaphylaxis. Children may present with different anaphylactic signs/symptoms based on age groups. Epinephrine is under-utilized and provider education on the proper management of drug-induced anaphylaxis is warranted. What is Known: • The most common causes of anaphylaxis in children are allergies to foods. Drugs are the second most common cause of pediatric anaphylaxis. • IM epinephrine is the recommended initial treatment of anaphylaxis. What is New: • Drug-induced anaphylaxis in pediatric patients has age-related clinical features. • IV bolus epinephrine was overused and associated with supratherapeutic dosing.
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Affiliation(s)
- Yan Xing
- Department of Pediatrics, Division of Pulmonology & Allergy, Peking University Third Hospital, Beijing, China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Shusen Sun
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA USA
| | - Xiang Ma
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Roy A. Pleasants
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Asthma, Allergy, and Airways Center, Durham, NC USA
| | - Huilin Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China ,Richard M. Fairbanks School of Public Health, Department of Epidemiology, Indiana University–Purdue University Indianapolis, Indianapolis, IN USA
| | - Hangci Zheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China ,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Tiansheng Wang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China. .,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China. .,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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21
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Chen K, Wang Q, Pleasants RA, Ge L, Liu W, Peng K, Zhai S. Empiric treatment against invasive fungal diseases in febrile neutropenic patients: a systematic review and network meta-analysis. BMC Infect Dis 2017; 17:159. [PMID: 28219330 PMCID: PMC5319086 DOI: 10.1186/s12879-017-2263-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/11/2017] [Indexed: 02/07/2023] Open
Abstract
Background The most optimal antifungal agent for empiric treatment of invasive fungal diseases (IFDs) in febrile neutropenia is controversial. Our objective was evaluate the relative efficacy of antifungals for all-cause mortality, fungal infection-related mortality and treatment response in this population. Methods Pubmed, Embase and Cochrane Library were searched to identify randomized controlled trials (RCTs). Two reviewers performed the quality assessment and extracted data independently. Pairwise meta-analysis and network meta-analysis were conducted to compare the antifungals. Results Seventeen RCTs involving 4583 patients were included. Risk of bias of included studies was moderate. Pairwise meta-analysis indicated the treatment response rate of itraconazole was significantly better than conventional amphotericin B (RR = 1.33, 95%CI 1.10–1.61). Network meta-analysis showed that amphotericin B lipid complex, conventional amphotericin B, liposomal amphotericin B, itraconazole and voriconazole had a significantly lower rate of fungal infection-related mortality than no antifungal treatment. Other differences in outcomes among antifungals were not statistically significant. From the rank probability plot, caspofungin appeared to be the most effective agent for all-cause mortality and fungal infection-related mortality, whereas micafungin tended to be superior for treatment response. The results were stable after excluding RCTs with high risk of bias, whereas micafungin had the lowest fungal infection-related mortality. Conclusions Our results highlighted the necessity of empiric antifungal treatment and indicates that echinocandins appeared to be the most effective agents for empiric treatment of febrile neutropenic patients based on mortality and treatment response. However, more studies are needed to determine the best antifungal agent for empiric treatment. Our systematic review has been prospectively registered in PROSPERO and the registration number was CRD42015026629. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2263-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ken Chen
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
| | - Qi Wang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Roy A Pleasants
- Duke University Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Long Ge
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
| | - Kangning Peng
- School of Basic Medical Sciences, Peking University Health Science Center, Beijing, 100191, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China.
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22
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Abstract
A number of new agents for the management of chronic obstructive pulmonary disease (COPD) are at different stages of development, including several inhaled long-acting antimuscarinics (LAMA). Long-acting bronchodilators are considered to be central to the management of COPD due to the evidence supporting their efficacy and safety. Umeclidinium, a LAMA, has recently been approved for the maintenance treatment of moderate to very severe COPD in a number of countries. This comprehensive review and pooled meta-analysis provides detailed information about the efficacy and safety of this agent. The pharmacokinetics and pharmacodynamics of umeclidinium observed in phase I and II studies support its once-daily administration. Umeclidinium is rapidly cleared from blood, and renal or hepatic impairment do not lead to significant changes in drug disposition. A pooled analysis of phase III and comparative studies of umeclidinium in patients with moderate to very severe COPD showed significant improvement in lung function measures, including trough forced expiratory volume in 1 s (FEV1), as well as in acute exacerbations of COPD, dyspnea, and quality of life. Adverse effects, including known anticholinergic effects, were uncommon with umeclidinium. Limited data suggest the efficacy of umeclidinium is similar to that of tiotropium. Umeclidinium is administered as a dry powder inhaler, provides adequate lung delivery in patients with moderate to very severe airflow obstruction, and appears to be easily used by patients. Umeclidinium provides a safe and effective option as an inhaled LAMA for the management of COPD.
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Affiliation(s)
- Roy A Pleasants
- Duke University Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Asthma, Allergy, and Airways Center, 1821 Hillandale Rd Suite 25A, Durham, NC, 27705, USA.
| | - Tiansheng Wang
- Department of Pharmacy Administration and Clinical Pharmacy, Peking University Health Science Center, Beijing, China
| | - Jinming Gao
- Department of Respiratory Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Huilin Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, UNC Chapel Hill, Chapel Hill, NC, USA
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23
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Abstract
The global burden of chronic obstructive pulmonary disease (COPD) continues to grow in part due to better outcomes in other major diseases and in part because a substantial portion of the worldwide population continues to be exposed to inhalant toxins. However, a disproportionate burden of COPD occurs in people of low socioeconomic status (SES) due to differences in health behaviors, sociopolitical factors, and social and structural environmental exposures. Tobacco use, occupations with exposure to inhalant toxins, and indoor biomass fuel (BF) exposure are more common in low SES populations. Not only does SES affect the risk of developing COPD and etiologies, it is also associated with worsened COPD health outcomes. Effective interventions in these people are needed to decrease these disparities. Efforts that may help lessen these health inequities in low SES include 1) better surveillance targeting diagnosed and undiagnosed COPD in disadvantaged people, 2) educating the public and those involved in health care provision about the disease, 3) improving access to cost-effective and affordable health care, and 4) markedly increasing the efforts to prevent disease through smoking cessation, minimizing use and exposure to BF, and decreasing occupational exposures. COPD is considered to be one the most preventable major causes of death from a chronic disease in the world; therefore, effective interventions could have a major impact on reducing the global burden of the disease, especially in socioeconomically disadvantaged populations.
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Affiliation(s)
- Roy A Pleasants
- Duke Asthma, Allergy, and Airways Center
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine
- Durham VA Medical Center, Durham, NC
| | - Isaretta L Riley
- Duke Asthma, Allergy, and Airways Center
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine
- Durham VA Medical Center, Durham, NC
| | - David M Mannino
- Division of Pulmonary, Critical Care, and Sleep Medicine, Pulmonary Epidemiology Research Laboratory, University of Kentucky, Lexington, KY, USA
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Wang T, Wang F, Xin X, Pleasants RA, Shi L. Methods for using microblogs for health communication with a pharmacist-based account. Patient Educ Couns 2016; 99:1432-1437. [PMID: 26979475 DOI: 10.1016/j.pec.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 02/13/2016] [Accepted: 03/04/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To implement and assess the effectiveness of using microblogging for health communication with a pharmacist-based account. METHODS We created a private and public "iPharmacist" account on the Weibo microblogging platform using the "Brief, Evidence-based, Ethical, and Plain-language (BEEP)" principle to post messages and to interact with patients. From November 2012 to November 2013, a content analysis was performed of the original microposts by iPharmacist, as well as original messages directed to iPharmacist by other accounts, and private messages received by iPharmacist. RESULTS A total of 598 original messages were posted by iPharmacist, which were reposted 34442 times with 6013 comments received; while 310 messages were posted by other Weibo users directed to the iPharmacist alone with 131 private messages. CONCLUSIONS The use of iPharmacist account allowed the provision of quality microposts to educate the Chinese public. The public messages were well disseminated. PRACTICE IMPLICATIONS Microblogging could be an effective tool for patient education and health communication.
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Affiliation(s)
- Tiansheng Wang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Fei Wang
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - Xiaoxiong Xin
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Roy A Pleasants
- Duke University Division of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, USA
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China.
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Wheaton AG, Pleasants RA, Croft JB, Ohar JA, Heidari K, Mannino DM, Liu Y, Strange C. Gender and asthma-chronic obstructive pulmonary disease overlap syndrome. J Asthma 2016; 53:720-31. [PMID: 27043854 DOI: 10.3109/02770903.2016.1154072] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess relationships between obstructive lung diseases, respiratory symptoms, and comorbidities by gender. METHODS Data from 12 594 adult respondents to the 2012 South Carolina Behavioral Risk Factor Surveillance System telephone survey were used. Five categories of chronic obstructive airway disease (OAD) were defined: former asthma only, current asthma only, chronic obstructive pulmonary disease (COPD) only, asthma-COPD overlap syndrome (ACOS), and none. Associations of these categories with respiratory symptoms (frequent productive cough, shortness of breath, and impaired physical activities due to breathing problems), overall health, and comorbidities were assessed using multivariable logistic regression for men and women. RESULTS Overall, 16.2% of men and 18.7% of women reported a physician diagnosis of COPD and/or asthma. Former asthma only was higher among men than women (4.9% vs. 3.2%, t-test p = 0.008). Current asthma only was more prevalent among women than men (7.2% vs. 4.7%, p < 0.001), as was ACOS (4.0% vs. 2.2%, p < 0.001). Having COPD only did not differ between women (4.3%) and men (4.4%). Adults with ACOS were most likely to report the 3 respiratory symptoms. COPD only and ACOS were associated with higher likelihoods of poor health and most comorbidities for men and women. Current asthma only was also associated with these outcomes among women, but not among men. CONCLUSIONS In this large population-based sample, women were more likely than men to report ACOS and current asthma, but not COPD alone. Gender differences were evident between the OAD groups in sociodemographic characteristics, respiratory symptoms, and comorbidities, as well as overall health.
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Affiliation(s)
- Anne G Wheaton
- a Division of Population Health , National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Roy A Pleasants
- b Division of Pulmonary, Allergy, and Critical Care Medicine , Duke University School of Medicine , Durham , NC , USA
| | - Janet B Croft
- a Division of Population Health , National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Jill A Ohar
- c Section on Pulmonary, Critical Care, Allergy & Immunologic Disease , Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Khosrow Heidari
- d Chronic Disease Epidemiology Office , South Carolina Department of Health and Environmental Control , Columbia , SC , USA
| | - David M Mannino
- e Division of Pulmonary, Critical Care, and Sleep Medicine , Pulmonary Epidemiology Research Laboratory , University of Kentucky , Lexington , KY , USA
| | - Yong Liu
- a Division of Population Health , National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Charlie Strange
- f Division of Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
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Pleasants RA, Heidari K, Wheaton AG, Ohar JA, Strange C, Croft JB, Liao W, Mannino DM, Kraft M. Targeting Persons With or At High Risk for Chronic Obstructive Pulmonary Disease by State-based Surveillance. COPD 2015; 12:680-9. [PMID: 26367193 PMCID: PMC4674427 DOI: 10.3109/15412555.2015.1043424] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The Behavioral Risk Factor Surveillance System (BRFSS) survey is used to estimate chronic obstructive pulmonary disease (COPD) prevalence and could be expanded to describe respiratory symptoms in the general population and to characterize persons with or at high risk for the disease. Tobacco duration and respiratory symptom questions were added to the 2012 South Carolina BRFSS. Data concerning sociodemographics, chronic illnesses, health behaviors, and respiratory symptoms were collected in 9438 adults ≥ 35 years-old. Respondents were categorized as having COPD, high risk, or low risk for the disease. High risk was defined as no self-reported COPD, ≥ 10 years' tobacco use, and ≥ 1 respiratory symptom (frequent productive cough or shortness of breath (SOB), or breathing problems affecting activities). Prevalence of self-reported and high-risk COPD were 9.1% and 8.0%, respectively. Overall, 17.3%, 10.6%, and 5.2% of all respondents reported activities limited by breathing problems, frequent productive cough, and frequent SOB, respectively. The high-risk group was more likely than the COPD group to report a productive cough and breathing problems limiting activities as well as being current smokers, male, and African-American. Health impairment was more severe in the COPD than the high-risk group, and both were worse than the low-risk group. CONCLUSIONS Persons at high risk for COPD share many, but not all, of the characteristics of persons diagnosed with the disease. Additional questions addressing smoking duration and respiratory symptoms in the BRFSS identifies groups at high risk for having or developing COPD who may benefit from smoking cessation and case-finding interventions.
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Affiliation(s)
- Roy A. Pleasants
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, and Durham VA Medical Center, Durham, North Carolina, USA
| | - Khosrow Heidari
- Chronic Disease Epidemiology Office, South Carolina Department of Health and Environmental Control, Columbia, South Carolina, USA
| | - Anne G. Wheaton
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jill A. Ohar
- Section on Pulmonary, Critical Care, Allergy & Immunologic Disease, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Charlie Strange
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Janet B. Croft
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Winston Liao
- Consultant, North Carolina COPD Taskforce, Cary, North Carolina, USA
| | - David M. Mannino
- Division of Pulmonary, Critical Care, and Sleep Medicine, Pulmonary Epidemiology Research Laboratory, University of Kentucky, Lexington, Kentucky, USA
| | - Monica Kraft
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
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Liu Y, Pleasants RA, Croft JB, Wheaton AG, Heidari K, Malarcher AM, Ohar JA, Kraft M, Mannino DM, Strange C. Smoking duration, respiratory symptoms, and COPD in adults aged ≥45 years with a smoking history. Int J Chron Obstruct Pulmon Dis 2015; 10:1409-16. [PMID: 26229460 PMCID: PMC4516194 DOI: 10.2147/copd.s82259] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The purpose of this study was to assess the relationship of smoking duration with respiratory symptoms and history of chronic obstructive pulmonary disease (COPD) in the South Carolina Behavioral Risk Factor Surveillance System survey in 2012. METHODS Data from 4,135 adults aged ≥45 years with a smoking history were analyzed using multivariable logistic regression that accounted for sex, age, race/ethnicity, education, and current smoking status, as well as the complex sampling design. RESULTS The distribution of smoking duration ranged from 19.2% (1-9 years) to 36.2% (≥30 years). Among 1,454 respondents who had smoked for ≥30 years, 58.3% were current smokers, 25.0% had frequent productive cough, 11.2% had frequent shortness of breath, 16.7% strongly agreed that shortness of breath affected physical activity, and 25.6% had been diagnosed with COPD. Prevalence of COPD and each respiratory symptom was lower among former smokers who quit ≥10 years earlier compared with current smokers. Smoking duration had a linear relationship with COPD (P<0.001) and all three respiratory symptoms (P<0.001) after adjusting for smoking status and other covariates. While COPD prevalence increased with prolonged smoking duration in both men and women, women had a higher age-adjusted prevalence of COPD in the 1-9 years, 20-29 years, and ≥30 years duration periods. CONCLUSION These state population data confirm that prolonged tobacco use is associated with respiratory symptoms and COPD after controlling for current smoking behavior.
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Affiliation(s)
- Yong Liu
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Ga, USA
| | - Roy A Pleasants
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Janet B Croft
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Ga, USA
| | - Anne G Wheaton
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Ga, USA
| | - Khosrow Heidari
- Chronic Disease Epidemiology Office, Department of Health and Environmental Control, South Carolina, SC, USA
| | - Ann M Malarcher
- Office of Smoking and Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jill A Ohar
- Section on Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University, Winston Salem, NC, USA
| | - Monica Kraft
- Department of Medicine, University of Arizona, Phoenix, AZ, USA
| | - David M Mannino
- Division of Pulmonary, Critical Care, and Sleep Medicine, Pulmonary Epidemiology Research Laboratory, University of Kentucky, Lexington, KY, USA
| | - Charlie Strange
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
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Liu Y, Pleasants RA, Croft JB, Lugogo N, Ohar J, Heidari K, Strange C, Wheaton AG, Mannino DM, Kraft M. Body mass index, respiratory conditions, asthma, and chronic obstructive pulmonary disease. Respir Med 2015; 109:851-9. [PMID: 26006753 DOI: 10.1016/j.rmed.2015.05.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/05/2015] [Accepted: 05/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aims to assess the relationship of body mass index (BMI) status with respiratory conditions, asthma, and chronic obstructive pulmonary disease (COPD) in a state population. METHODS Self-reported data from 11,868 adults aged ≥18 years in the 2012 South Carolina Behavioral Risk Factor Surveillance System telephone survey were analyzed using multivariable logistic regression that accounted for the complex sampling design and adjusted for sex, age, race/ethnicity, education, smoking status, physical inactivity, and cancer history. RESULTS The distribution of BMI (kg/m(2)) was 1.5% for underweight (<18.5), 32.3% for normal weight (18.5-24.9), 34.6% for overweight (25.0-29.9), 26.5% for obese (30.0-39.9), and 5.1% for morbidly obese (≥40.0). Among respondents, 10.0% had frequent productive cough, 4.3% had frequent shortness of breath (SOB), 7.3% strongly agreed that SOB affected physical activity, 8.4% had current asthma, and 7.4% had COPD. Adults at extremes of body weight were more likely to report having asthma or COPD, and to report respiratory conditions. Age-adjusted U-shaped relationships of BMI categories with current asthma and strongly agreeing that SOB affected physical activity, but not U-shaped relationship with COPD, persisted after controlling for the covariates (p < 0.001). Morbidly obese but not underweight or obese respondents were significantly more likely to have frequent productive cough and frequent SOB than normal weight adults after adjustment. CONCLUSION Our data confirm that both underweight and obesity are associated with current asthma and obesity with COPD. Increased emphasis on exercise and nutrition may improve respiratory conditions.
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Affiliation(s)
- Yong Liu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, USA.
| | - Roy A Pleasants
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Janet B Croft
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, USA
| | - Njira Lugogo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jill Ohar
- Section on Pulmonary, Critical Care, Allergy & Immunologic Disease, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Khosrow Heidari
- Chronic Disease Epidemiology Office, South Carolina Department of Health and Environmental Control, Columbia, SC, USA; Department of Epidemiology & Statistics, University of South Carolina, Columbia, SC, USA
| | - Charlie Strange
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, USA
| | - Anne G Wheaton
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, USA
| | - David M Mannino
- Division of Pulmonary, Critical Care, and Sleep Medicine, Pulmonary Epidemiology Research Laboratory, University of Kentucky, Lexington, KY, USA
| | - Monica Kraft
- Department of Medicine, University of Arizona, Phoenix, AZ, USA
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Abstract
Chronic obstructive pulmonary disease (COPD) and asthma are common airway disorders characterized by chronic airway inflammation and airflow obstruction, and are a leading cause of morbidity and mortality in the People's Republic of China. These two diseases pose a high economic burden on the family and the whole of society. Despite evidence-based Global Initiative for Chronic Obstructive Lung Disease and Global Initiative for Asthma guidelines being available for the diagnosis and management of COPD and asthma, many of these patients are not properly diagnosed or managed in the People's Republic of China. The value of combination therapy with inhaled corticosteroids and long-acting β2-agonists has been established in the management of asthma and COPD globally. Combinations of inhaled corticosteroids and long-acting β2-agonists such as fluticasone and salmeterol, have been shown to be effective for improving symptoms, health status, and reducing exacerbations in both diseases. In this review, we discuss the efficacy and safety of this combination therapy from key studies, particularly in the People's Republic of China.
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Affiliation(s)
- Jinming Gao
- Department of Respiratory Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Roy A Pleasants
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Pleasants RA, Ohar JA, Croft JB, Liu Y, Kraft M, Mannino DM, Donohue JF, Herrick HL. Chronic obstructive pulmonary disease and asthma-patient characteristics and health impairment. COPD 2013; 11:256-66. [PMID: 24152212 DOI: 10.3109/15412555.2013.840571] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
UNLABELLED Abstract Background: Persons with chronic obstructive pulmonary disease (COPD) and/or asthma have great risk for morbidity. There has been sparse state-specific surveillance data to estimate the impact of COPD or COPD with concomitant asthma (overlap syndrome) on health-related impairment. METHODS The North Carolina (NC) Behavioral Risk Factor Surveillance System (BRFSS) was used to assess relationships between COPD and asthma with health impairment indicators. Five categories [COPD, current asthma, former asthma, overlap syndrome, and neither] were defined for 24,073 respondents. Associations of these categories with health impairments (physical or mental disability, use of special equipment, mental or physical distress) and with co-morbidities (diabetes, coronary heart disease, stroke, arthritis, and high blood pressure) were assessed. RESULTS Fifteen percent of NC adults reported a COPD and/or asthma history. The overall age-adjusted prevalence of any self-reported COPD and current asthma were 5.6% and 7.6%, respectively; 2.4% reported both. In multivariable analyses, adults with overlap syndrome, current asthma only, and COPD only were twice as likely as those with neither disease to report health impairments (p < 0.05). Compared to those with neither disease, adults with overlap syndrome and COPD were more likely to have co-morbidities (p < 0.05). The prevalence of the five co-morbid conditions was highest in overlap syndrome; comparisons with the other groups were significant (p < 0.05) only for diabetes, stroke, and arthritis. CONCLUSIONS The BRFSS demonstrates different levels of health impairment among persons with COPD, asthma, overlap syndrome, and those with neither disease. Persons reporting overlap syndrome had the most impairment and highest prevalence of co-morbidities.
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Affiliation(s)
- Roy A Pleasants
- 1Campbell University College of Pharmacy and Health Sciences and Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine , Durham, NC , USA
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Pleasants RA, Herrick H, Liao W. The prevalence, characteristics, and impact of chronic obstructive pulmonary disease in North Carolina. N C Med J 2013; 74:376-383. [PMID: 24165761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. We describe the prevalence, characteristics, and impact of COPD in North Carolina. METHODS We determined the prevalence of self-reported COPD and characteristics of affected persons using data from the 2009 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) survey. We also determined the number of persons with COPD in nursing homes and adult care or family care homes. We drew conclusions about the impact of COPD from data regarding mortality, hospitalizations, emergency department visits, prednisone use, and health impairment. RESULTS The age-adjusted prevalence of COPD among BRFSS survey respondents was 5.6%, and about 10,000 adults in nursing homes, adult care homes, or family care homes had COPD; thus we estimate that nearly 408,000 adults in North Carolina had COPD in 2009. Rates of self-reported COPD were highest among elderly individuals, smokers, individuals with less education, and those with lower incomes. Mental and physical impairment were significantly worse in those with COPD, two-thirds of whom reported that dyspnea affected their quality of life. Prednisone use was reported by 27.4% of persons with COPD, 11.4% of respondents with COPD had been hospitalized for this condition within the preceding year, and COPD admissions accounted for 1.44% of all hospital charges. Asthma, heart disease, stroke, and diabetes mellitus were significantly more common in persons with COPD. In terms of mortality, COPD was the fourth leading cause of death (n = 4,324); 77% of COPD deaths were among persons who had no education beyond high school, and 53% of those who died were women. COPD was reported in 17.1% of deaths from all causes, 21% of deaths from asthma, 10.1% of deaths from lung cancer, and 6.7% of deaths from heart disease. LIMITATIONS These data are based on population and health care database estimates and are approximations. CONCLUSION COPD has substantial effects on the health of North Carolinians.
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Affiliation(s)
- Roy A Pleasants
- Campbell University, College of Pharmacy and Health Sciences, Division of Pharmacy Practice, Leslie Campbell Ave., Buies Creek, NC 27506, USA.
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Abstract
In 2002, an estimated 11.2 million adults in the United States had chronic obstructive pulmonary disease (COPD). Guidelines for the management of the disease have been published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the American Thoracic Society-European Respiratory Society. Several other organizations are in the process of preparing guidelines for COPD, most based on the GOLD report. The most important pharmacologic intervention in COPD is treatment with bronchodilator drugs. This intervention applies not only to stable COPD, but also to exacerbations (flares) of the disease. Prevention strategies have been developed for acute exacerbations, and management strategies include using short-acting beta(2)-agonists, systemic corticosteroids, and antibiotics, in both at home and hospital settings.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine,Durham, North Carolina 27707, USA
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Pleasants RA, Haden D. An update on chronic obstructive pulmonary disease. ACTA ACUST UNITED AC 2006; 20:965-75. [PMID: 16548673 DOI: 10.4140/tcp.n.2005.965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Provide an update on the diagnosis and management of chronic obstructive pulmonary disease (COPD) based on new international and national guidelines. COPD affects approximately 5% to 7% of adults in the United States, with a higher prevalence in elderly persons (10% in elderly males). DATA SOURCE A Medline search of relevant articles and the Global Initiative for Obstructive Lung Disease and the American Thoracic Society/European Respiratory Society COPD Guidelines. STUDY SELECTION Articles and current guidelines relevant to pharmacists working with COPD patients in extended-care facilities. DATA SYNTHESIS COPD is a chronically progressive disease that ultimately leads to major health impairment. New international and national guidelines recently have become available; these guidelines provide extensive insight into many aspects of the disease. Key interventions include early diagnosis, use of pulmonary-function testing, smoking cessation, supplemental oxygen, pulmonary rehabilitation, optimization of pharmacological therapies, and preventing--as well as minimizing--the impact of acute exacerbations of COPD. Optimizing the use of bronchodilators and, in selected patients, the use of corticosteroids are especially important pharmacological interventions in the management of COPD. Patients are started on short-acting bronchodilators; long-acting agents can be added and, in some patients, inhaled corticosteroids can be added as well. Other pharmacological interventions include smoking cessation therapies and the use of anti-infective and mucolytics/expectorants. CONCLUSION Pharmacists can assist in proper drug selection and administration in COPD patients in long-term care facilities. In addition, they can assist in preventing complications of drug therapy such as steroid-induced osteoporosis.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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Balkrishnan R, Nelsen LM, Kulkarni AS, Pleasants RA, Whitmire JT, Schechter MS. Outcomes associated with initiation of different controller therapies in a Medicaid asthmatic population: a retrospective data analysis. J Asthma 2005; 42:35-40. [PMID: 15801326 DOI: 10.1081/jas-200044769] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Outcomes in asthmatic patients may vary depending on the controller medication used. Observational studies of outcomes of asthma therapy are needed to understand the implications of choice of controller in different populations. OBJECTIVES To determine whether there are differences in health care use and costs of asthma treatment in asthma patients treated with montelukast compared with fluticasone proponiate 44 microg. METHOD Using data from the North Carolina Medicaid program, we compared continuously enrolled asthmatic patients starting either fluticasone propionate 44 microg (FP44), an inhaled corticosteroid (ICS) (n = 312), or montelukast 5 and 10 mg, an oral leukotriene modifier (LM) (n = 398) between the years 1998 and 1999. A secondary analysis compared continuously enrolled asthmatic patients already using ICS as controller therapy initiating either salmeterol (long-acting beta-agonist) (n = 97) or montelukast (n = 101) in the year 1998. Patients were followed for 1 year pre- and postcontroller or additional controller initiation for health care service use, medication refill patterns, and costs. RESULTS There were no significant differences in the adjusted asthma-related health care costs between the montelukast and FP44 groups. In both groups, physician visits were significantly higher in year 2 (p < 0.01) than in year 1. We found montelukast users to be more adherent with prescription refills (using measures of medication possession) even after allowing for a wider adherence range for FP (RR = 2.53; 95% CI = 1.50-4.26), although patients using montelukast were more likely than patients with fluticasone to switch controller pharmacotherapy (RR = 1.53; 95% CI = 1.12-2.09). Similarly, there were no differences in health care service use and costs between the montelukast and salmeterol groups, with the exception of a 33% reduction (p < 0.01) in number of inhaled corticosteroid refills in the second year in the salmeterol group. CONCLUSION There were no cost and major health care use differences between the two primary or secondary controller therapies in the postinitiation year. Although FP was associated with lower rate of controller switch, montelukast use was associated with significantly better treatment adherence in patients with treatment persistence in this population of Medicaid-enrolled asthmatic patients. The addition of salmeterol as additional controller was associated with a significant decrease in inhaled corticosteroid use, suggesting decreased adherence in patients on the two-drug regimen.
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Affiliation(s)
- Rajesh Balkrishnan
- Ohio State University College of Pharmacy and School of Public Health, Columbus, Ohio 43210, USA.
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Pleasants RA. Book Review: Drugs for the Treatment of Respiratory Diseases. Ann Pharmacother 2004. [DOI: 10.1345/aph.1d435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Roy A Pleasants
- Clinical Pharmacist, Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina, Associate Professor, Department of Pharmacy Practice, Campbell University School of Pharmacy, Buies Creek, North Carolina
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Pleasants RA, Michalets EL, Williams DM, Samuelson WM, Rehm JR, Knowles MR. Pharmacokinetics of vancomycin in adult cystic fibrosis patients. Antimicrob Agents Chemother 1996; 40:186-90. [PMID: 8787903 PMCID: PMC163080 DOI: 10.1128/aac.40.1.186] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Although the depositions of many antibiotics are altered in cystic fibrosis patients, that of vancomycin has not been studied. To assess vancomycin pharmacokinetics, 10 adult cystic fibrosis patients were given a parenteral dose of vancomycin (15 mg/kg) during the first 72 h of hospitalization for acute bronchopulmonary exacerbation. Blood samples were obtained at 0, 1, 1.25, 1.5, 2, 3, 4, 6, 8, 12, 15, and 24 h. The mean (standard deviation) weight, measured creatinine clearance, and Taussig clinical score were 51 (13) kg, 130 (39) ml/min/1.73 m2, and 64 (13), respectively. Multicompartmental pharmacokinetic parameters were best described by a two-compartment model. The mean (standard deviation) volume of distribution, total body clearance, and terminal elimination rate constant were 0.58 (0.15) liter/kg, 91 (19) ml/min/1.73 m2, and 0.123 (0.05) h-1, respectively. These values were consistent with vancomycin pharmacokinetic parameters obtained in previous studies of healthy adult volunteers. Vancomycin dosages predicted by using a two-compartment Bayesian model were approximately 15 mg/kg every 8 to 12 h. There were poor correlations between clinical score or creatinine clearance and any pharmacokinetic parameter (r values of < 0.32). The coefficient of correlation between urine flow rate and total body clearance was 0.7 (P < 0.05). Adult cystic fibrosis patients exhibit a disposition of vancomycin similar to that exhibited by healthy adults, and thus cystic fibrosis does not alter vancomycin pharmacokinetics.
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Affiliation(s)
- R A Pleasants
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
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Abstract
Certain antibiotics, particularly piperacillin, have been reported to be associated with a high incidence of allergic reactions in patients with cystic fibrosis. We initiated a study to determine the relative frequency of allergic reactions, ie, drug-induced fever and rash, to parenteral beta-lactam antibiotics in adult patients with cystic fibrosis. Charts of 111 patients were reviewed for each hospitalization to assess allergic reactions. Of 90 evaluable patients, 26 patients developed one or more allergic reactions to beta-lactam antibiotics. The number of allergic reactions per number of patients receiving specific antibiotics were carbenicillin (4/56), mezlocillin (7/42), piperacillin (11/31), ticarcillin (1/20), cefazolin (0/24), ceftazidime (1/35), imipenem/cilastatin (4/16), and nafcillin (3/36). The mean time to onset of drug-induced fever or of rash was 9.1 days. As a group penicillins had a higher frequency of allergic reactions than cephalosporins. The frequency of reactions was greatest with acylaminopenicillins (mezlocillin and piperacillin) and imipenem/cilastatin. The results of this study indicate that in addition to piperacillin, mezlocillin and imipenem/cilastatin may be associated with a high incidence of allergic reactions in patients with CF.
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Affiliation(s)
- R A Pleasants
- Department of Pharmacy, Duke University Medical Center, University of North Carolina at Chapel Hill
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Pleasants RA, Kessler JM. Drug allergies, adverse drug reactions, and the patient record. Am J Hosp Pharm 1993; 50:1363. [PMID: 8362869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Pleasants RA, Kessler JM. Drug Allergies, Adverse Drug Reactions, and the Patient Record. Am J Health Syst Pharm 1993. [DOI: 10.1093/ajhp/50.7.1363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - John M. Kessler
- Assistant Director Departrnent of Pharmacy Duke University Medical Uenter Box 3089 Durham. NC 27710
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Abstract
OBJECTIVE To report a case of possible ciprofloxacin-induced arthropathy in an adult patient with cystic fibrosis (CF). CASE SUMMARY A 25-year-old man with CF received three separate courses of ciprofloxacin therapy at usual doses for acute pulmonary exacerbations of his disease. During the second and third courses, the patient experienced bilateral swelling of his knees between two to three weeks after initiation of each course. Both times symptoms markedly decreased after discontinuation of the drug. The patient had no prior history of arthropathy. Furthermore, during the last two acute exacerbations of his CF, he did not receive ciprofloxacin and did not experience any symptoms of arthropathy. DISCUSSION Prior cases of quinolone-induced arthropathy involving pediatric CF patients or adult patients without CF have been reported in the literature. We report the first case of such an arthropathy in an adult patient with CF. The findings are supported by a rechallenge with the drug. CONCLUSIONS It is likely that ciprofloxacin may produce arthropathy in adult as well as pediatric patients with CF. Quinolones should be considered as a possible cause of arthropathy in adult CF patients.
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Affiliation(s)
- W M Samuelson
- Department of Medicine, Duke University Medical Center, Durham, NC
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Pleasants RA, Vaughan LM, Williams DM, Fox JL. Compatibility of ceftazidime and aminophylline admixtures for different methods of intravenous infusion. Ann Pharmacother 1992; 26:1221-6. [PMID: 1421642 DOI: 10.1177/106002809202601004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Aminophylline and ceftazidime are sometimes used concurrently in patients with respiratory disorders. Parenteral aminophylline usually is administered as a constant infusion, and ceftazidime is given intermittently or less commonly as a constant infusion. We evaluated the stability and compatibility of the two drugs when aminophylline is given as a constant intravenous infusion and ceftazidime is administered simultaneously either through a y-site (piggyback method) or as a continuous infusion (constant infusion method). DESIGN The chemical stability of intravenous aminophylline and ceftazidime in dextrose 5% and NaCl 0.9% for both methods was studied. Three different formulations of ceftazidime from the same manufacturer were studied (minibag using reconstituted ceftazidime, premixed minibag, and ceftazidime arginine). For the piggyback and constant infusion methods, samples were collected at 0, 1, and 2 hours; and 0, 6, and 24 hours, respectively. All experiments were conducted in triplicate. Samples were analyzed in duplicate by a stability-indicating HPLC assay method. OUTCOME MEASURE Ceftazidime and aminophylline were considered stable if concentrations remained above 90 percent of the original concentrations over the time periods studied. RESULTS Ceftazidime was determined to be compatible with aminophylline in the piggyback method. In contrast, when aminophylline and ceftazidime were admixed in the same intravenous container (constant infusion method), the two drugs were not stable. CONCLUSIONS These data indicate that aminophylline and ceftazidime admixtures are incompatible when prepared in the same intravenous container, which may occur if both are given as a constant infusion. The two drugs are compatible when the ceftazidime is piggybacked into a primary intravenous set in which aminophylline is administered as a constant infusion.
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Affiliation(s)
- R A Pleasants
- Department of Pharmacy, Duke University Medical Center, Durham, NC 27710
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Himmelberg CJ, Pleasants RA, Weber DJ, Kessler JM, Samsa GP, Spivey JM, Morris TL. Use of antimicrobial drugs in adults before and after removal of a restriction policy. Am J Hosp Pharm 1991; 48:1220-7. [PMID: 1858800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The effects on the quantity and quality of antimicrobial drug use of removing an antimicrobial restriction policy are reported. Monthly totals for the number of courses of antimicrobial therapy and expenditures based on grams used were obtained from pharmacy records on adult inpatients for a portion (July-December 1987) of the restriction policy term and for the six months (July-December 1988) immediately after the policy ended. Data were obtained for nine restricted drugs and for three that were never restricted. Retrospective drug-use reviews were conducted for ceftazidime and imipenem-cilastatin. For the restricted agents, the total number of courses of therapy increased by 158% after the restriction policy was removed, and total expenditures increased by 103%. There were no significant changes in the number of courses of therapy or cost for the unrestricted antimicrobials. In the postrestriction period, ceftazidime and imipenem-cilastatin were used more often in patients who were less critically ill. Inappropriate use of imipenem-cilastatin occurred significantly more often after the restrictions were removed. Other factors potentially affecting the use of antimicrobials, such as patient age and the incidence of nosocomial infections, did not differ substantially between the two periods. The removal of an antimicrobial restriction policy resulted in increased use of and higher expenditures for previously restricted agents, as well as an increase in the inappropriate use of at least one agent.
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Affiliation(s)
- C J Himmelberg
- Middle Tennessee Regional Poison and Clinical Toxicology Center, Vanderbilt University Medical Center, Nashville
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Himmelberg CJ, Pleasants RA, Weber DJ, Kessler JM, Samsa GP, Spivey JM, Morris TL. Use of antimicrobial drugs in adults before and after removal of a restriction policy. Am J Health Syst Pharm 1991. [DOI: 10.1093/ajhp/48.6.1220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Cheryl J. Himmelberg
- Middle Tennessee Regional Poison and Clinical Toxicology Center, Vanderbilt University Medical Center, Nashville, TN; at the time of this study she was Drug Information Resident, University of North Carolina Hospitals (UNCH), and Clinical Instructor, School of Pharmacy, University of North Carolina (UNC), Chapel Hill
| | - Roy A. Pleasants
- Non-affiliated Area Health Education Center, Duke University Medical Center (DUMC), Durham, NC, and Clinical Assistant Professor, School of Pharmacy, UNC; at the time of this study he was Senior Clinical Specialist in Infectious Diseases, UNCH, and Clinical Assistant Professor, School of Pharmacy, UNC
| | - David J. Weber
- Hospital Epidemiology, UNCH, and Assistant Professor of Medicine, Pediatrics and Epidemiology, School of Medicine, UNC
| | - John M. Kessler
- Clinical Services, DUMC, and Clinical Associate Professor, School of Pharmacy, UNC; at the time of this study he was Director, Drug Information Services, UNCH, and Clinical Assistant Professor, School of Pharmacy, UNC
| | - Gregory P. Samsa
- Veterans Affairs Center for Health Services Research in Primaiy Care, and Assistant Professor, Division of Biometiy, Department of Community and Family Medicine, DUMC
| | - J. Michael Spivey
- The Clinical Pharmacokinetics Laboratory Millard Fillmore Hospital, Buffalo, NY; at the time of this study he was a doctor of pharmacy degree candidate, School of Pharmacy, UNC
| | - Theresa L. Morris
- Rex Hospital, Raleigh, NC; at the time of this study she was Patient Care Unit Pharmacist, UNCH
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Williams DM, Pleasants RA. Comment: metered-dose inhalers. DICP 1989; 23:815-6. [PMID: 2815863 DOI: 10.1177/106002808902301025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Pleasants RA, Williams DM, Fus AS, Leathers CM, Waltner WE. Tobramycin administration and blood sampling through a dual-lumen peripheral intravenous catheter. DICP 1989; 23:460-3. [PMID: 2741479 DOI: 10.1177/106002808902300604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The objective of this study was to determine if a peripheral dual-lumen catheter could be used for accurate tobramycin blood concentration measurement when drug administration and blood sampling were undertaken through separate lumens of the catheter. Eleven adult volunteers received tobramycin 1.5 mg/kg iv infused over 30 minutes through the distal lumen of the dual-lumen catheter every eight hours for two doses. Multiple blood samples were obtained concurrently from the proximal lumen of the catheter and a single-lumen catheter in the contralateral arm after each dose. Blood samples were also obtained through the distal lumen before and 30 minutes after the end of the infusion. Accurate blood samples were obtainable through the dual-lumen catheter in only 5 of 11 subjects due to either infiltration or difficulties in catheter placement. In the subjects from whom accurate blood samples were obtained, approximately 20 minutes postinfusion was the amount of time required before measured tobramycin serum concentrations were similar between the arm in which the drug was infused (site of the dual-lumen catheter) and the contralateral arm. At standard times for obtainment of trough (just prior to the infusion) and peak (30 minutes after the end of a 30-minute infusion) tobramycin serum concentrations from the proximal lumen of the dual-lumen catheter were numerically similar to those obtained from the contralateral arm. This preliminary study indicates that the dual-lumen catheter provides accurate aminoglycoside concentrations when patent relative to blood withdrawal and if peak blood samples are obtained at least 30 minutes postinfusion through the recommended lumen. However, further study in a larger number of subjects is required before routine use of this device can be recommended.
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Affiliation(s)
- R A Pleasants
- Department of Pharmacy, North Carolina Memorial Hospital, Chapel Hill 27514
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Abstract
Spironolactone and one of its metabolites, canrenone, cross-react with some digoxin immunoassays to result in erroneous serum digoxin concentrations. Recently, additional compounds, 7-alpha-thiomethylspirolactone (7-a-TMS) and 6-beta-hydroxy-7-alpha-thiomethylspirolactone (6-B-OH-7-a-TMS), have been reported to be quantitatively important metabolites of spironolactone. This study was initiated to evaluate the cross-reactivity of these metabolites, canrenone, and spironolactone with four different digoxin immunoassays. Blank serum was spiked with each compound to yield concentrations reported to occur in vivo. Samples were analyzed in duplicate by each of the following immunoassays: fluorescence polarization immunoassay (FPIA); affinity-column-mediated immunoassay (ACMIA); radioimmunoassay (RIA); and enzyme immunoassay (EIA). The 7-a-TMS metabolite cross-reacted with both the RIA and ACMIA methods. Apparent digoxin concentrations were as great as 0.39 ng/ml for this metabolite at the highest concentration evaluated, 600 ng/ml. At the lowest concentrations evaluated with the 7-a-TMS metabolite, 50 ng/ml, apparent digoxin concentrations as high as 0.28 ng/ml were reported. The 6-B-OH-7-a-TMS metabolite did not cross-react to a significant extent with any of immunoassays studied. Canrenone cross-reacted with the ACMIA method at a concentration of 100 ng/ml. The EIA method exhibited no apparent cross-reactivity with any of the compounds, whereas the FPIA method exhibited minimal cross-reactivity. The results of this study indicate that the 7-a-TMS metabolite cross-reacts to a significant extent with some immunoassays; however, this is not true for the 6-B-OH-7-a-TMS metabolite.
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Affiliation(s)
- R A Pleasants
- Department of Pharmacy, North Carolina Memorial Hospital, Chapel Hill
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Pleasants RA, Sawyer WT, Williams DM, McKenna WR, Brown JM, Powell JR. Accuracy of tobramycin delivery by four i.v. infusion methods. Clin Pharm 1988; 7:367-73. [PMID: 3383542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The accuracy of tobramycin delivery by four methods of intermittent intravenous infusion was studied in 11 healthy male volunteers. Subjects received intravenous tobramycin (as the sulfate salt) 1.5 mg/kg by each of four infusion methods in a nonblinded, randomized, four-way crossover design. The methods used for intravenous infusion were (1) minibag via gravity flow (MG), (2) minibag with the secondary infusion tubing inserted below a volumetric infusion pump (MP), (3) metered chamber via volumetric infusion pump (MC), and (4) syringe pump (SP). Doses were diluted to a volume of 50 mL, except for the two minibag methods, for which the dilution was necessarily greater because of manufacturer overfill. Intravenous flow rates for both primary fluid and drug administration were set at 100 mL/hr, and the duration of drug infusion was documented by observation for each administered dose. The fluid volume of 12 minibags was measured to assess manufacturer overfill. Fluid remaining in the secondary i.v. tubing for the minibag methods was collected after the infusion. Seventeen blood samples were obtained before and at various time intervals after each dose and analyzed in duplicate for tobramycin content by fluorescence polarization immunoassay. A mean of 10% of each dose remained in the secondary i.v. tubing at the completion of the infusion for the minibag methods, whereas less than 1% of each dose remained in the secondary tubing for the SP method.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R A Pleasants
- Department of Pharmacy, North Carolina Memorial Hospital, Chapel, NC 27514
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Pleasants RA, Sawyer WT, Williams DM, McKenna WR, Powell JR. Effect of four intravenous infusion methods on tobramycin pharmacokinetics. Clin Pharm 1988; 7:374-9. [PMID: 3383543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The influence of four intermittent intravenous infusion methods on the determination of tobramycin pharmacokinetic values and predicted doses was evaluated in 11 healthy adult volunteers. Each subject received tobramycin (as the sulfate salt) 1.5 mg/kg by each of four i.v. infusion methods: (1) minibag via gravity flow (MG), (2) minibag with the secondary infusion tubing inserted below a volumetric pump (MP), (3) metered chamber via volumetric pump (MC), and (4) syringe pump (SP). Infusion rates were initially set to administer each dose over a 30-minute period. Sixteen blood samples were obtained over an eight-hour period before and at various time intervals after each dose and were analyzed for tobramycin content by fluorescence polarization immunoassay. Area under the serum concentration-time curve from time zero to infinity (AUC0-infinity) was calculated by the trapezoidal rule. Serum tobramycin concentration data for each subject were fitted to a biexponential decay model with zero-order input. beta and V beta were calculated from fitted data. One-compartment pharmacokinetic values, elimination rate constant (kappa), apparent volume of distribution (V), and predicted doses to achieve steady-state peak concentrations of 6 micrograms/mL were calculated by the method of Sawchuk and Zaske. There were no significant differences in either beta or kappa among the infusion methods. V beta values (mean +/- S.D.) for the methods were 0.240 +/- 0.025 (MG), 0.257 +/- 0.025 (MP), 0.221 +/- 0.027 (MC), and 0.231 +/- 0.032 (SP) L/kg.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R A Pleasants
- Department of Pharmacy, North Carolina Memorial Hospital, Chapel Hill 27514
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