Tiotropium (Spiriva) Found Beneficial In Early Stages of COPD

MedicalResearch.com Interview with:
Dr Prof Nanshan Zhong
, MD (Edin), FRCS (Edin), FRCP and
Pixin Ran PhD

National Center for Respiratory Diseases, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital

MedicalResearch.com: What is the background for this study? What are the main findings?

Response:    According to the latest research, in 2015, 3.2 million people died from COPD globally, with an increase of 11.6% in mortality compared with that in 1990 (GBD 2015 Chronic Respiratory Disease Collaborators. Lancet Respir Med. 2017,5:691-706). COPD has now become the third leading cause of death worldwide and is estimated to become the disease with the seventh greatest burden worldwide in 2030. In China, the prevalence was 8.2% among people aged 40 years or greater, according to our epidemiological survey in 2007.

Importantly, current international guidelines have been mainly focusing on the management of moderate-to-severe COPD. However, among this patient cohort, the severely impaired lung function can only be reversed to a very limited extent despite the most potent treatment combinations. Patients with more advanced COPD are frequently associated with a significantly higher mortality and incidence of re-hospitalization and disability, which cause tremendous economic burden for both the families and the society. However, more than 70% of COPD patients are currently categorized as having stage I to early stage II COPD, most of whom have no or very few respiratory symptoms (Zhong NS, et al. Am J Respir Crit Care Med. 2007, 176:753-760; Mapel DW, et al. Int J COPD 2011; 6: 573−581). The vast majority of these patients would have the “COPD assessment Test” (CAT) score of 10 or lower (range: 0 to 40, with higher scores indicating more severe COPD). Admittedly, no medication has been recommended for this patient cohort according to the latest international guidelines. In real-world practice, these patients are almost neglected by physicians and have received virtually no medication. Nonetheless, the annual lung function decline rates among these patients are the most rapid among all COPD patients. (Bhatt SP, et al. Am J Respir Crit Care Med 2015; 191: A2433). An important clinical question has been raised regarding whether an intervention strategy targeting at early stages of COPD can possibly make the airflow limitation more reversible or prevent from further deterioration.

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Which Patients With Advanced Respiratory Disease Die in the Hospital?

MedicalResearch.com Interview with:

Dr Sabrina Bajwah MBChB MRCGP MSc MA PhD Consultant Palliative Medicine, King’s College NHS Foundation Trust Honorary Senior Lecturer King's College London Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation London, UK

Dr Sabrina Bajwah

Dr Sabrina Bajwah
MBChB MRCGP MSc MA PhD
Consultant Palliative Medicine, King’s College NHS Foundation Trust
Honorary Senior Lecturer
King’s College London
Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation
London, UK 

MedicalResearch.com: What is the background for this study?

Response: Where people die is often important to them and their families, as well as being important for planning health care services. Most people want to die at home, but instead most die in hospital. While the trends have been studied in cancer, other diseases, such as respiratory, are rarely looked at even though they are common and increasing causes of death.

Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Pulmonary Diseases (IPD) are common respiratory conditions. Both conditions result in a high use of hospital services, especially among people in advanced stages. This leads to high healthcare costs.1 In the UK in 2010, it is estimated that IPD costs £16.2 million per year in hospitalisations.2 The NHS spends more than £810 million annually managing COPD, with inpatient stays accounting for around £250 million annually.

Understanding which factors affect place of death is vital for planning services and improving care, especially given our ageing population, rising chronic diseases and the high costs of hospital admissions. Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated.

We aimed to determine the trends and factors associated with dying in hospital in COPD and IPD, and the impact of a national end of life care (EoLC) strategy3 to reduce deaths in hospital. This study analysed a national data set of all deaths for COPD and IPD, covering 380,232 people over 14 years.

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Antipsychotics Raise Risk of Respiratory Failure in COPD

MedicalResearch.com Interview with:
Meng-Ting Wang, PhD

Associate Professor
School of Pharmacy
National Defense Medical Center
Taipei, Taiwan

MedicalResearch.com: What is the background for this study?

Response: During the past decades, there have been multiple case reports about acute respiratory distress or acute respiratory failure (ARF) from the use of antipsychotics. Nevertheless, no population-based studies have been conducted to examine this potential drug safety issue. We aimed to investigate the association between use of antipsychotics and risk of ARF in a population of chronic obstructive pulmonary disease (COPD), who is vulnerable to ARF and frequently prescribed with antipsychotics.

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Real World Trial Show Efficacy of Fluticasone Furoate–Vilanterol for COPD in Clinical Practice

MedicalResearch.com Interview with:
Jørgen Vestbo DMSc FRCP FERS

Professor of  Respiratory Medicine
Division of Infection, Immunity and Respiratory Medicine
University of Manchester
Education and Research Centre
University Hospital of South Manchester
Manchester

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Efficacy studies are limited in their usefulness to clinicians as there are often restricted inclusion criteria, with many exclusion criteria and patients are followed closely with high adherence to study treatment. They therefore show what the drugs can do but not necessarily what they do do in the real world.

Randomised studies in everyday practice, not limiting the entry (effectiveness trials) are therefore needed.

In our study we showed that it is feasible to do randomised studies in the “real world”.

Our study showed that a simple treatment with a once-daily combination of an inhaled corticosteroid and a long-acting beta-agonist (Breo/Relvar) was superior to the usual care chose by the patients’ general practitioners to manage their COPD.

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Eosinophil Count Identifies COPD Patients Who May Benefit From Inhaled Steroids

MedicalResearch.com Interview with:

Danny MvBryan, MD Vice president, Clinical Development & Medical Affairs, Respiratory Boehringer Ingelheim Pharmaceuticals, Inc.

Dr. Danny MvBryan

Danny McBryan, MD
Vice president, Clinical Development & Medical Affairs, Respiratory
Boehringer Ingelheim Pharmaceuticals, Inc.

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. MvBryan: The new post-hoc analysis from the WISDOM study shows a routine blood test could help identify the small minority of patients with severe or very severe COPD who may benefit from the addition of inhaled corticosteroids (ICS). This post-hoc analysis was recently published online in The Lancet Respiratory Medicine.

For 80 percent of patients in the WISDOM study, the use of ICS on top of SPIRIVA HANDIHALER (a long-acting muscarinic antagonist – LAMA) and salmeterol (a long-acting beta-agonist – LABA) had no additional benefit in reducing the risk of exacerbations, compared to SPIRIVA HANDIHALER and the LABA without ICS.

The post-hoc analysis shows that these patients can be easily identified by measuring the level of white blood cells, called eosinophils. Patients with levels lower than 4 percent (300 cells/µL) were associated with a lack of response to ICS.

The WISDOM study evaluated stepwise withdrawal of inhaled corticosteroids (ICS) in severe to very severe COPD patients with a history of exacerbation. WISDOM was a 12-month, double-blind, parallel-group, active-controlled study in which all patients received triple therapy (tiotropium 18 μg once daily, salmeterol 50 μg twice daily and fluticasone 500 μg twice daily) for a six-week run-in period. Patients were randomized 1:1 to continue triple therapy or stepwise withdrawal of ICS over 12 weeks (dose reduction every six weeks).

The WISDOM data show that in patients with severe to very severe COPD, the risk of moderate/severe exacerbations during one year of follow-up was non-inferior between those patients who continued on inhaled corticosteroids and those where ICS therapy was withdrawn in a stepwise manner.

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Simple Blood Test To Identify COPD Patients Who Will Benefit from Inhaled Steroids

MedicalResearch.com Interview with:
Dr Henrik Watz MD
Pulmonary Research Institute at Lung Clinic Grosshansdorf
Airway Research Center North, German Center for Lung Research
Grosshansdorf, Germany

Medical Research: What is the background for this study? What are the main findings?

Dr Watz : While bronchodilators are the mainstay therapy for all patients with COPD some patients benefit from the addition of inhaled corticosteroids in case of frequent exacerbations. So far only little data exist that help clinicians to better characterize those patients that may benefit from the continuation of inhaled corticosteroids on top of dual bronchodilation with a LABA and a LAMA.

Post-hoc analyses of the WISDOM dataset suggest that those patients, who have blood eosinophil counts of 4 % or greater or 300 eosinophils per µL or more have less exacerbations, when inhaled corticosteroids are continued compared to patients, in whom inhaled corticosteroids are withdrawn. Patients with less than 4 % eosinophils or less than 300 eosinophils in peripheral blood, who represent 80 % of the study population in WISDOM, did not benefit from a continuation of inhaled corticosteroids.

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Task Force Recommends Against Routine COPD Screening in Asymptomatic Adults

MedicalResearch.com Interview with:

Dr. William Phillips MD MPH USPSTF Task Force member and Theodore J. Phillips Endowed Professor in Family Medicine University of Washington, Seattle. Dr. Phillips is also a founder and senior associate editor of the Annals of Family Medicine

Dr. William Phillips

Dr. William Phillips MD MPH
USPSTF  Task Force member and
Theodore J. Phillips Endowed Professor in Family Medicine
University of Washington, Seattle. Dr. Phillips is also a founder and senior associate editor of the Annals of Family Medicine

MedicalResearch.com: What is the background for this study? What are the main findings? 

Dr. Phillips: Chronic obstructive respiratory disease, or COPD, is a serious, chronic condition that affects a person’s ability to breathe. It is the third leading cause of death in the United States. When the Task Force reviewed the research on screening adults for COPD in a primary care setting, we concluded with moderate certainty that screening has no net benefit, which is why we do not recommend screening for COPD in people who do not have symptoms.

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COPD Patients On Oxygen Therapy Should Be Warned Of Burn Risks

Gulshan Sharma, MD, MPH Division of Pulmonary Critical Care and Sleep Medicine University of Texas Medical Branch Galveston, TXMedicalResearch.com Interview with:
Gulshan Sharma, MD, MPH
Division of Pulmonary Critical Care and Sleep Medicine
University of Texas Medical Branch
Galveston, TX

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Sharma: Thirty-five years ago, two multicenter trials reported substantial improvements in survival and quality of life with continuous oxygen therapy in the treatment of severe hypoxemia associated with chronic obstructive pulmonary disease (COPD).

Notably, aside from smoking cessation, no other medical intervention therapy has been shown to improve survival for patients with COPD. It is estimated that upto a third of the patients who are prescribed oxygen continue to smoke.

Using large claims data of Medicare beneficiaries with COPD, we found that patients with COPD who had a burn injury were more likely to have been prescribed oxygen therapy in the preceding 90 days compared to the control subjects.

Patients with COPD on oxygen who had burn injury, the face, head and neck region were more commonly involved. In the U.S. oxygen is prescribed to an estimated one million Medicare beneficiaries, based on our estimates a physician would have to treat 1,421 patients with oxygen therapy for one year to cause one burn injury. Continue reading

Healthy Diet May Lower COPD Risk

MedicalResearch.com Interview with:
Raphaëlle Varraso
INSERM U1168, VIMA (Aging and chronic diseases. Epidemiological and public health approaches), 16 avenue Paul Vaillant Couturier
Villejuif, France

MedicalResearch: What is the background for this study? What are the main findings?

Response: Respiratory health and lung function, strongly predict general health status and all-cause mortality. Chronic obstructive pulmonary disease (COPD) is currently ranked the third leading cause of death worldwide. The predominant risk factor for COPD in the developed world is cigarette smoking, but up to one-third of COPD patients have never smoked, suggesting that other factors are involved. Besides smoking, relatively little attention has been paid to other modifiable risk factors that might decrease risk of developing COPD, including diet. The Alternate Healthy Eating Index (AHEI)-2010, a new measure of diet quality based on current scientific knowledge, has been linked to risk of major chronic diseases, such as cardiovascular disease, diabetes and cancer. However, the role of dietary scores on risk of COPD is unknown.

We examined this issue among >120,000 US female and male health professionals (Nurses’ Health Study and Health Professionals Follow-up Study), and we reported that a high AHEI-2010 dietary score score (reflecting high intakes of whole grains, vegetables, fruit, polyunsaturated fatty acids, nuts and legumes, and long-chain omega-3 fats, a moderate intake of alcohol, and low intakes of red/processed meats, trans fat, sodium and sugar-sweetened beverages) was associated with a lower risk of COPD in both women and men. This novel finding supports the importance of diet in COPD pathogenesis.
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COPD: Most Hospital Readmissions Not Due To COPD

Tina Shah, MD University of Chicago Medicine Department of Pulmonary and Critical Care University of ChicagoMedicalResearch.com Interview with:
Tina Shah, MD
University of Chicago Medicine
Department of Pulmonary and Critical Care
University of Chicago

Medical Research: What is the background for this study? What are the main findings?

Dr. Shah: The reason why we undertook this study is to better understand the Medicare COPD population that falls under the purview of the CMS Hospital Readmissions Reduction Program (HRRP). This program places up to a 3% penalty on all Medicare revenues for hospitals that take care of beneficiaries should a hospital exceed its “expected readmission rate.” Previously 30 day readmissions after index admissions for congestive heart failure, acute myocardial infarction and pneumonia fell subject to the HRRP. As of October 2014, COPD has been added to the list, despite minimal evidence to guide hospitals in how to curb COPD readmissions. The goal of this research was to provide an epidemiological background for this population and identify trends as a hypothesis generating first step to predict who is most likely to be readmitted and to identify targets for successful future interventions on this group. Our study population is unique in that we longitudinally look at about 1/2 of all Medicare admissions for COPD exacerbations, using the CMS guideline definition which is based on discharge ICD-9 codes. As described in previous literature, there is a large discrepancy between identification of COPD by provider versus coding algorithm, however since the Hospital Readmissions Reduction Program is based on discharge coding it is important to examine this particular group.
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