roflumilast Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible lung disease that is often associated with chronic bronchitis or emphysema and is typically characterized by symptoms such as breathlessness, chronic cough, and excessive production of mucus. A marked worsening of symptoms (i.e., exacerbation) may last for several weeks and be severe enough to require hospitalization. COPD is the fourth leading cause of death in the United States and is most often caused by cigarette smoking. The medications used most often in the treatment of COPD include bronchodilators (e.g., beta 2-adrenergic receptor agonists [e.g., salmeterol (Serevent)], anticholinergic agents [tiotropium (Spiriva)]), and inhaled corticosteroids (budesonide, fluticasone propionate [that are used in combination formulations {Symbicort, Advair} with a beta2agonist]). The specific agent(s) used depends on the severity of the symptoms and the urgency for treatment. In 2011, two new therapeutic agents were approved for the treatment of COPD, and these agents are considered on an individual basis in the following discussions. Roflumilast (Daliresp—Forest) and its active metabolite (roflumilast N-oxide) are selective inhibitors of the enzyme phosphodiesterase 4 (PDE4). PDE4 is a major cyclic-3’,5’-adenosine monophosphate (cAMP)-metabolizing enzyme in lung tissue, and inhibition of this enzyme results in accumulation of intracellular cAMP. Although the specific mechanism of action through which roflumilast provides its therapeutic benefit has not been fully clarified, it is thought to be related to the effects of increased intracellular cAMP in lung cells and a resultant reduction of inflammation. Roflumilast is specifically indicated as a treatment to reduce the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations. It has not been evaluated for the treatment of COPD associated with emphysema. The new drug is not a bronchodilator and is not indicated for the relief of acute bronchospasm. The effectiveness of roflumilast was demonstrated in multiple studies, including two 1-year trials in which more than 1,500 patients were treated with the new drug. The rate of moderate or severe exacerbations in those treated with roflumilast was reduced significantly compared with placebo, with a 15% reduction in exacerbations in one trial and an 18% reduction in the other. The clinical benefit provided has been described by many as “modest,” and an initial question has been posed as to whether the benefit was greater than the risk of systemic adverse events associated with the drug. However, the potential for the drug to provide additional benefit for patients with severe COPD, as well as the limited and specific focus of the indication to be included in the labeling, resulted in the drug’s approval by the Food and Drug Administration (FDA). The adverse events most frequently experienced in the clinical studies of roflumilast included diarrhea (10%), nausea (5%), headache (4%), back pain (3%), and insomnia (2%). Weight loss was reported in 8% of patients treated with roflumilast compared with 2% of those receiving placebo. In the 1-year studies, 20% of patients treated with the new drug experienced moderate weight loss (defined as between 5% and 10% of body weight) compared with 7% of those who received placebo. Patients treated with roflumilast should have their weight monitored regularly. Psychiatric adverse events (e.g., insomnia, anxiety, depression) were reported more often (6%) in patients treated with roflumilast than in those receiving placebo (3%). Suicidal ideation and behavior have been reported, and patients, their caregivers, and families should be informed of the importance of being alert for the emergence or worsening of insomnia, anxiety, depression, suicidal thoughts, or other mood changes. Roflumilast is classified in Pregnancy Category C and should not be used in a pregnant woman unless the anticipated benefit justifies the risk to the fetus. It should not be used during labor or delivery or by women who are nursing. The effectiveness and safety of roflumilast in pediatric patients have not been evaluated. Following oral administration, the absolute bioavailability of roflumilast is approximately 80%. The drug is converted to its active metabolite primarily via the cytochrome P450 (CYP)1A2 and -3A4 pathways. Although the parent drug is three times as potent as its metabolite, the plasma exposure of the metabolite is about 10-fold greater. Roflumilast is not detectable in the urine, and only a trace amount of the active metabolite is present. Dosage adjustment is not necessary in patients with impaired renal function. The use of roflumilast is contraindicated in patients with moderate to severe hepatic impairment, and caution must be exercised if it is used in patients with mild impairment of hepatic function. The activity of the new drug may be increased by the concurrent use of
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