Chest Medicine Made Easy-Dr Deepu: COPD

Showing posts with label COPD. Show all posts

Statins in Asthma COPD overlap may bring down the risk of CAD and stroke risk

By Dr Deepu

Recently published study in atherosclerosis journal has found that the risk for CAD was lower in all statin-treated patients with ACOS. Whereas the risk for ischemic stroke was lower only in long-term statin users with ACOS. There was no link between risk for hemorrhagic stroke and statin use.

A retrospective cohort study was conducted using data from the Longitudinal Health Insurance Database, which included 1 million enrollees in the Taiwan National Health Insurance program from January 1, 2000, through December 31, 2011.

Patients ≥20 years of age with ACOS who were treated with statins (n=916) and those who did not receive statin therapy (n=6338) were enrolled in the study. Investigators examined the cumulative incidence of CAD and stroke (both ischemic and hemorrhagic) with the use of time-dependent Cox proportional regression. Following adjustments for age, sex, inhaled corticosteroid use, oral steroid use, and comorbidities, adjusted hazard ratios (aHRs) and 95% CIs for CAD or stroke in statin users (long-term statin use: >600 days; short-term statin use: ≤600 days) were compared with these values in statin nonusers.

In statin users, the aHRs for CAD and stroke were 0.50 (95% CI, 0.41-0.62) and 0.83 (95% CI, 0.63-1.09), respectively. Furthermore, aHRs for ischemic and hemorrhagic stroke were 0.30 (95% CI, 0.09-0.99) and 0.90 (95% CI, 0.68-1.20), respectively. In addition, in long-term statin users, aHRs for CAD and stroke were 0.23 (95% CI, 0.13-0.41) and 0.42 (95% CI, 0.19-0.89), respectively. In short-term statin users, aHRs for CAD and stroke were 0.58 (95% CI, 0.47-0.71) and 0.93 (95% CI, 0.70-1.23), respectively.

A major limitation of the current study is that lipid levels were not taken into account. Moreover, although a new-user study design was employed, with propensity score matching and a time-dependent model for analysis, results were not as accurate as those derived from randomized controlled trials.

The investigators concluded that regardless of the duration of statin use, the risk for CAD was lower in all statin-treated patients with ACOS. In contrast, the risk for ischemic stroke was lower only in long-term statin users with ACOS, and no link was observed between risk for hemorrhagic stroke and use of statin therapy.

The study was published in atherosclerosis journal

Regular aspirin use may reduce progression of COPD, study suggests

By Dr Deepu

Regular aspirin use was associated with a more than 50% reduction in emphysema/chronic obstructive pulmonary disease (COPD) progression in an elderly cohort over a decade in a longitudinal analysis of data from a large lung study, researchers reported.
The findings were published in the journal CHEST.
The important findings of the Study are:

*Emphysema increased 0.60 percentage points over 10 years (95% CI 0.35 to 0.94) on an average.

*Aspirin users showed slower progression of percent emphysema was compared to non-aspirin users (fully adjusted model: -0.34% per 10 years, 95% CI -0.60 to -0.08; P=0.01).

*Results were similar in ever-smokers and for doses of 81 mg and 300-325 mg. A greater magnitude effect was seen among participants with airflow limitations.

*No association was found between aspirin use and change in lung function.
The association was seen in a wide range of aspirin usage, and was greatest in older study participants with significant airflow obstruction.
These findings, along with supportive results in animals, suggest that further study of aspirin and platelet activation in emphysema may be warranted.
They mentioned that platelet activation reduces pulmonary microvascular blood flow and contributes to inflammation, which has been shown to be important in the pathogenesis of COPD/emphysema.

The hypothesis of the Study was that regular use of aspirin, a platelet-inhibitor, would be associated with slower progression of emphysema-like lung on computed tomography (CT), and slower decline in lung function. Percent emphysema assessment was limited to the lower two-thirds of the lungs and baseline differences in emphysema were significant among aspirin users and non-users, with users having a greater percent emphysema.
The study used data from the Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study, which assessed the percentage of emphysema-like lung below-950 Hounsfield units ("percent emphysema") on cardiac and full-lung CT. There were 4,257 participants from the MESA Lung Study. Their mean (±SD) age was 61±10 years, 54% were ever-smokers, and 22% used aspirin regularly.

Spirometry was conducted during 2004-2007 and repeated in 2010-2012 in accordance with American Thoracic Society-European Respiratory Society guidelines following the MESA Lung protocol.
The airflow obstruction was defined as pre-bronchodilator FEV₁/FVC <0.70 and restrictive ventilatory defect as FVC<lower limit of normal and FEV₁/FVC≥0.7.
Regular aspirin use included 3 or more days per week and mixed effects models adjusted for demographics, anthropometry, smoking, hypertension, ACE-inhibitor use, C-reactive protein, sphingomyelins, and scanner factors.
Results were similar after propensity score weighting and when the exposure was defined as any aspirin use at baseline, and there was no evidence for effect modification associated with age and race/ethnicity.
Results were also similar after adjustment for inhaler, NSAID, COX-2 inhibitor, ADP-receptor inhibitors, statin, and diuretic use.
This is the first study of which we are aware to show an association between aspirin use and longitudinal progression of percent emphysema.
Prior studies have found platelet-receptor related genes serotonin receptor 4 (HTR4), von Willebrand factor (VWF) and its platelet-receptor, GP1BA, to be associated with FEV₁ and COPD. Additionally, platelet factor 4 increased emphysema when added to a neutrophil elastase animal model of emphysema, and platelet activation was found to be greater in COPD compared to controls, and during exacerbation.

Noninvasive ventilation may be beneficial for patients with acute hypercapnic respiratory failure during COPD exacerbations, data indicate

By Dr Deepu

A review of a recent meta-analysis published in the Annals of Emergency Medicine indicates that noninvasive ventilation provides benefit in patients with acute hypercapnic respiratory failure during chronic obstructive pulmonary disease (COPD) exacerbations, reducing mortality and the need for mechanical ventilation.

Authors also added that noninvasive ventilation also may improve length of hospital stay, serum pH, and oxygen partial pressure. The meta-analysis included 17 randomized controlled trials with 1264 patients.

The review authors noted that severe COPD is characterized by hyperinflation, airway obstruction, and decreased respiratory muscle function. In this setting, exacerbation can result in hypercarbic respiratory failure. Usual care includes controlled oxygenation, bronchodilators, corticosteroids, and antibiotics. If these interventions fail, intubation is initiated.

Limitations of the meta-analysis include the variability of usual care and noninvasive ventilation duration in the studies, the potential for publication bias regarding the need for intubation, and low heterogeneity for both mortality and the need for intubation.

The meta-analysis provides strong evidence that noninvasive ventilation reduces mortality, the need for intubation, and hospital length of stay in patients with acute hypercapnic respiratory failure during an acute exacerbation of COPD. The findings support a trial of noninvasive ventilation in patients with a pH of less than 7.30 before proceeding with intubation.

ICS/LABA exacerbation benefit outweighs pneumonia

By Dr Deepu

The benefit of a fixed-dose inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) combination in reducing exacerbations of chronic obstructive pulmonary disease (COPD) far outweighed any risk for pneumonia in a post hoc analysis of the 48-week FORWARD study.

Although there were 13 extra pneumonia events when a fixed-dose combination of beclometasone diproprionate and formoterol fumarate (Foster, Chiesi Farmaceutici SpA) was used as compared to formoterol fumarate alone, there were 123 fewer moderate to severe COPD exacerbations over a 342-day analysis period.
The FORWARD study was a two-arm trial designed to compare the efficacy and safety of fixed-dose treatment with beclometasone diproprionate and formoterol fumarate versus formoterol fumarate alone in 1,199 patients with severe COPD.

For inclusion in the study, patients had to have a post-bronchodilator forced expiratory volume in 1 second below 50% of predicted and a forced vital capacity ratio of less than 0.7. They also had to have a smoking history of 10 pack-years or more, and a history of at least one COPD exacerbation in the previous 12 months that had required treatment or hospitalization (Eur RespirJ. 2013;41[1]:12-7).

After a 2-week run-in period, where all patients received a 24-mcg dose of formoterol fumarate, patients were randomized to continue treatment with formoterol fumarate or to receive the fixed-dose combination of beclometasone diproprionate 400 mcg and beclometasone diproprionate 24 mcg for 48 weeks.

A total of 1,186 patients, most of whom were male (69%) with a mean age of 64 years, formed the intention-to-treat population.

Published results (Respir Med. 2014;108[8]:1153-62) showed that the combination of the ICS beclometasone diproprionate and the LABA formoterol fumarate (Chiesi Farmaceutici SpA) was associated with a 28% reduction in the annual rate of moderate to severe exacerbations versus the LABA alone.

The adjusted rate of exacerbations per patient per year was 0.80 in patients treated with the ICS/LABA combination versus 1.12 for those treated with just the LABA, with an adjusted rate ratio of 0.72 (P less than .001).

The published data also showed that pneumonia was reported by 23 patients (3.8%) treated with the ICS/LABA and by 11 (1.8%) treated with the LABA only.

For the new analysis, pneumonia and COPD exacerbations were looked in more detail, plotting out the cumulative number of events over time and also characterizing the types of pneumonia in more detail.

All patients had a chest x-ray to confirm the presence of pneumonia, he said, there were 35 cases of pneumonia, 24 occurring in patients treated with the fixed-dose beclometasone diproprionate and formoterol fumarate combination and 11 in patients treated only with formoterol fumarate.

Of these cases, 25 required in-hospital treatment – 16 patients in the ICS/LABA arm and 9 in the LABA-only arm. There were three instances of patients acquiring pneumonia in hospital – two in the ICS/LABA and one in the LABA-only arm.

There were also two fatal cases of pneumonia – one in each treatment group. Neither were thought to be related to either of the treatments.

These findings are in line with a recent review of the use of ICS for COPD by the European Medicines Agency (EMA/488280/2016), which noted that “overall the benefits of inhaled corticosteroid medicines in treating COPD continue to outweigh their risks and there should be no change to the way in which these medicines are used.”

The European Medicines Agency advised that patients and clinicians need to “be alert for signs and symptoms of pneumonia, bearing in mind that the clinical features of pneumonia overlap with those of a worsening (exacerbation) of the underlying disease.”

Implanted Coils In Lungs May Benefit People With Severe Emphysema

By Dr Deepu

The AP (1/13, Tanner) reports that research published in the Journal of the American Medical Association suggests that a new “minimally invasive way to treat severe breathing problems caused by” emphysema “showed modest but promising benefits.” This “technique involves inserting several small metal alloy coils through a scope into the lungs, aiming to tighten diseased tissue and open up healthy airways.” The research “involved 100 patients randomly assigned to receive usual care or coil treatment at 10 hospitals.”

Here is the abstract

Importance Therapeutic options for severe emphysema are limited. Lung volume reduction using nitinol coils is a bronchoscopic intervention inducing regional parenchymal volume reduction and restoring lung recoil.

Objective To evaluate the efficacy, safety, cost, and cost-effectiveness of nitinol coils in treatment of severe emphysema.

Design, Setting, and Participants Multicenter 1:1 randomized superiority trial comparing coils with usual care at 10 university hospitals in France. Enrollment of patients with emphysema occurred from March to October 2013, with 12-month follow-up (last follow-up, December 2014).

Interventions Patients randomized to usual care (n = 50) received rehabilitation and bronchodilators with or without inhaled corticosteroids and oxygen; those randomized to bilateral coil treatment (n = 50) received usual care plus additional therapy in which approximately 10 coils per lobe were placed in 2 bilateral lobes in 2 procedures.

Main Outcomes and Measures The primary outcome was improvement of at least 54 m in the 6-minute walk test at 6 months (1-sided hypothesis test). Secondary outcomes included changes at 6 and 12 months in the 6-minute walk test, lung function, quality of life as assessed by St George’s Respiratory Questionnaire (range, 0-100; 0 being the best and 100 being the worst quality of life; minimal clinically important difference, ≥4), morbidity, mortality, total cost, and cost-effectiveness.

Results can be seen through the link

Conclusions and Relevance In this preliminary study of patients with severe emphysema followed up for 6 months, bronchoscopic treatment with nitinol coils compared with usual care resulted in improved exercise capacity with high short-term costs. Further investigation is needed to assess durability of benefit and long-term cost implications.

Some Physicians Using Stem Cell Therapy To Treat COPD

By Dr Deepu

Fox News (1/8) reports that some physicians are using stem cells drawn from a “patient’s buttocks or midsection during liposuction” to treat chronic obstructive pulmonary disorder (COPD). After the stem cells are separated in a centrifuge, they are “mixed in a solution, which is administered through an IV and put into a nebulizer, from which the patient inhales them.”

you can get more information in Fox News Channel and Dr Borentsein website

FDA Approves Asthma Indication For COPD Drug.

Food and Drug Administration has approved “the long-acting muscarinic antagonist tiotropium bromide (Spiriva Respimat, Boehringer Ingelheim) for long-term maintenance treatment of asthma in people aged 12 years and older.” The drug has already been approved for treating chronic obstructive pulmonary disease (COPD).

U.S. FDA latest regulatory authority to approve tiotropium in asthma following authorities in the EU, Japan and other countries
Recent GINA 2015 Global Strategy recommends tiotropium by soft mist inhaler as add-on asthma therapy

Ingelheim, Germany, 16. September, 2015 – Boehringer Ingelheim today announced that the U.S. Food and Drug Administration (FDA) approved SPIRIVA® Respimat®(tiotropium bromide) Inhalation Spray for use in the treatment of asthma. It is approved by the FDA for the long-term, once-daily, maintenance treatment of asthma in patients 12 years of age and older. Following previous regulatory approvals, tiotropium by soft-mist inhaler has been included in the recently updated Global Initiative for Asthma report (GINA) 2015 Global Strategy for Asthma Management and Prevention.

Almost one in two patients with asthma still experience symptoms while receiving maintenance therapy, putting them at increased risk of potentially life-threatening asthma exacerbations. Pivotal, Phase III study results show that Spiriva® Respimat® as an add-on treatment to ICS/LABA maintenance therapy:

Significantly improves asthma symptoms
- patients are 68% more likely to improve asthma control7
Significantly reduces the risk of patients having a severe asthma exacerbation by a fifth (21%)
- reducing the number of patients who experienced a severe asthma exacerbation

The Phase III study results also showed that the safety of SPIRIVA® Respimat® is balanced as compared to placebo.

E-Cigarettes Not Gateway Drug Among British Youth, Survey Says

By Dr Deepu
The Guardian (UK) (8/17, Meikle) reports that an online survey by the British anti-tobacco group Action On Smoking and Health found that “experimentation with e-cigarettes is rising among 11- to 18-year-olds in Britain but is most common among those who already smoke or who have done in the past.” The group suggests that the results show it is “unlikely” that e-cigarettes are being used as a gateway drug to tobacco. Also covering the story are the Daily Mail (UK) (8/17, Duell) and the Independent (UK). (8/17, Connor)

COPD GUIDELINES

By Dr Deepu

An Official ATS/ERS Statement: Research questions in COPD (2015)

Official ATS/ERS Technical Standards: Field walking tests in chronic respiratory disease (2014)

An Official ATS/ERS Systematic Review: Measurement properties of field walking tests in chronic respiratory disease (2014)

Online supplement

An Official ATS/ERS Statement: Upper Limb Muscle Dysfunction in COPD (2014)

Full text version

Executive summary

American Thoracic Society/European Respiratory Society Statement: Standards for the Diagnosis and Management of Individuals with Alpha-1 Antitrypsin Deficiency (2003) Being Revised.

An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation (2013)

An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation (Executive Summary)(2013)

An Official ATS Workshop Report: The Integrated Care of the COPD Patient (2012)

An Official ATS/ACCP Statement: The Choosing Wisely Top 5 List in Adult Pulmonary Medicine (2014)

COPD Guideline NICE COPD Guidelines 2010

COPD Guidelines (2004)

Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society (2011)

Executive Summary: Prevention of Acute Exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline (April 2015)

Novel Risk Factors and the Global Burden of COPD (2010)

Outcomes for COPD pharmacological trials: from lung function to biomarkers (2008)

Outcomes for COPD pharmacological trials: from lung function to Biomarkers ATS / ERS Task Force 2008

Prevention of Acute Exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline (April 2015)

Standards for the diagnosis and treatment of patients with COPD ATS / ERS Task Force 2004

Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper (2004)

Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper ATS / ERS Task Force 2004

Update on the Mechanisms, Assessment, and Management of Dyspnea (2012)

FDA approves new drug STIOLTO for airway diseases.

By Dr Deepu

Patients with COPD and asthma have yet another medicinal option as Stiolto was approved in May 2015 by the U.S. Food and Drug Administration (US FDA). The medicine should now be available in pharmacies around the U.S. and few other countries.

The medicine is in the list of ever growing combination medicines approved for asthma and COPD.

Stiolto contains:

Tiotropium bromide (Spiriva), a long acting anticholinergic (LAAC)
Olodaterol (Striverdi), a long acting beta adrenergic (LABA)

Studies showed Spiriva by itself improved lung function. another study has showed that Spiriva used in combination with Symbicort, a medicine that contains both a LABA and an inhaled corticosteroid, improves lung function by as much as 62 percent.

Before concluding I want to emphasise the fact that, approved medicine might benefit in people who are not relieved with other medicines. They are class of ultra long acting drugs so the dosage frequency is decreased which on a long run may decrease the treatment cost and also need for rescue medicines.

Time has to tell whether this medicine combination with satisfy the end user I.e the patient himself has to decide whether it works or not.

CHRONIC BRONCHITIS V/S EMPHYSEMA. LEARNERS GUIDE.

Every medical student is aware that COPD is classically differentiated into chronic bronchitis and the emphysema. Even though this differentiation is not much useful in prescribing medicines, the difference plays a vital role in managing the acute patients. Here are the differences between the two forms of COPD.