LABA Research Articles

Proportion of Allergic Bronchopulmonary Aspergillosis Presenting as Difficult-to-control Asthma in Patients Attending a Tertiary Care Centre using the Modified ISHAM Criteria: A Cross-sectional Study

Introduction: Difficult-to-control asthmatics, as defined by the Global Initiative for Management of Asthma (GINA), belong to a subset of patients whose symptoms remain uncontrolled despite adhering to maximal optimised therapy. Complex hypersensitivity reactions in response to airway colonization with Aspergillus fumigatus, which occurs in patients with asthma or cystic fibrosis, are established factors for a poor response to treatment and frequent exacerbations. Only limited data related to Allergic Bronchopulmonary Aspergillosis (ABPA) is available from India, particularly from Kerala. Aim: To assess the occurrence of ABPA in patients with difficultto-control asthma using the modified ISHAM criteria. Materials and Methods: This cross-sectional analysis was conducted in the Department of Pulmonary Medicine, Institute of Chest Diseases, Government Medical College, Kozhikode, Kerala, India from February 2019 to July 2020. The study population comprised asthmatics attending the Pulmonary Medicine Outpatient Services who were on regular medications, including optimal doses of inhaled corticosteroid and longacting beta-agonist combinations. Patients with two or more exacerbations per year requiring systemic steroids for symptom control and a positive skin test for Aspergillus fumigatus antigen were further analysed using the modified International Society for Human and Animal Mycology (IHAM) criteria to determine the proportion of difficult-to-control asthmatics with ABPA. A total of 185 subjects were enrolled. Twelve patients opted out of the study, and the remaining 173 patients were screened using the modified ISHAM criteria. Statistical analysis was performed using Stastistical Packages of Social Sciences (SPSS) software version 21.0. Continuous parameters were expressed as mean and median, while categorical parameters were measured as frequency and percentages. Results: It was observed that 104 (60.1%) patients belonged to the age group between 41-60 years, while approximately 60 patients (34.7%) were below 40 years of age. Among the 173 patients, 86 (49.7%) tested positive for Aspergillus fumigatus antigen. Applying the ISHAM criteria, it was found that only 17 (9.8%) of these patients satisfied the criteria for co-existent ABPA. A total of 101 patients (58.4%) required at least one hospital admission, while 4 (2.3%) patients required more than three hospital admissions per year. Total 21 (12.1%) patients had IgE specific to Aspergillus fumigatus, while total IgE levels were elevated in 46 (26.6%) cases. Thirty-six cases (20.8%) had a high peripheral eosinophil count. Conclusion: This study suggests the possibility of the treating physician overlooking 10% of asthmatics in this region who are being managed as difficult-to-control asthma, but who have co-existent ABPA. This subset should be identified early in the course and managed separately for better treatment response.

Efficacy of Combination Therapy in Patients with Stable Coronary Heart Disease with Comorbid Chronic Obstructive Pulmonary Disease

The objective: to analyze the quality of life (QoL) and functional status after combination therapy in patients with stable coronary heart disease (CHD) and comorbid chronic obstructive pulmonary disease (COPD). Materials and methods. The study included 60 men with stable CHD in combination with COPD. The patients were divided into two groups of 30 people, comparable according to the main indicators. Study group (1) received basic treatment with nebivolol, valsartan, eplerenone, acetylsalicylic acid, rosuvastatin for CHD and basic COPD treatment with combination of umeclidinium bromide (a long-acting cholinolytic) and vilanterol (a long-acting beta2-agonist). Patients from Group 2 in addition tj the basic treatment received L-arginine in the form of an infusion of 4.2% 100 ml solution for 10 days, followed by oral administration at a dose of 3 g per day. The duration of treatment was 6 months. Quality of life was evaluated by validated standardized non-specific questionnaire «The 36-Item Short Form Health Survey» (SF-36), a validated specific respiratory questionnaire of St. George’s Hospital – St. George’s Respiratory Questionnaire (SGRQ). The functional state of patients before and after treatment was evaluated by cardiorespiratory test, which included the distance 6-minutes walk test (6MWT) according to the standard method in combination with pulse oximetry (SpO2), calculation of desaturation level (ΔSpO2), recording of electrocardiogram and blood pressure before and after exercise. Results. After the treatment, patients in both groups noted a significant improvement in quality of life across all domains of the SF-36 questionnaire, which includes 36 questions with physical and mental components. Patients from group 2 demonstrated better results of treatment in all indicators of physical functioning, general health and vital activity than patients from group 1. The results of the quality of life evaluation according to the specific respiratory questionnaire SGRQ also showed a significant improvement in patients of both groups. In both groups, the distance of 6MWT significantly increased, the heart rate at rest and after exercise decreased, and the level of desaturation decreased. In group 2, the increase in the distance of 6MWT, the decrease of desaturation level was significantly better than in group 1. Conclusions. Rational combination treatment of patients with stable coronary heart disease (CHD) with comorbid chronic obstructive pulmonary disease (COPD) includes nebivolol, valsartan, eplerenone, acetylsalicylic acid, rosuvastatin and a combination of vilanterol and umeclidinium bromide, contributes to improving the quality of life of patients and their functional status. Addition of L-arginine to the basic combination treatment of patients with CHD and COPD increases the efficacy of therapy and improves cardiohemodynamics. Addition of L-arginine to the treatment complex contributed to the additional improvement of the physical and mental patterns of quality of life and indicators of cardiorespiratory test.

Utility of Hypoglycemic Agents to Treat Asthma with Comorbid Obesity.

Adults with obesity may develop asthma that is ineffectively controlled by inhaled corticosteroids and long-acting beta-adrenoceptor agonists. Mechanistic and translational studies suggest that metabolic dysregulation that occurs with obesity, particularly hyperglycemia and insulin resistance, contributes to altered immune cell function and low-grade systemic inflammation. Importantly, in these cases, the same proinflammatory cytokines believed to contribute to insulin resistance may also be responsible for airway remodeling and hyperresponsiveness. In the past decade, new research has emerged assessing whether hypoglycemic therapies impact comorbid asthma as reflected by the incidence of asthma, asthma-related emergency department visits, asthma-related hospitalizations, and asthma-related exacerbations. The purpose of this review article is to discuss the mechanism of action, preclinical data, and existing clinical studies regarding the efficacy and safety of hypoglycemic therapies for adults with obesity and comorbid asthma.

Long COVID outcomes in an asthmatic cohort and its implications for asthma control

Long COVID outcomes in an asthmatic cohort and its implications for asthma control

Exercise capacity and physical activity in COPD patients treated with a LAMA/LABA combination: a systematic review and meta-analysis

BackgroundPersistent airflow limitation and dyspnoea may reduce chronic obstructive pulmonary disease (COPD) patients exercise capacity and physical activity, undermining their physical status and quality of life. Long-acting muscarinic antagonists and long-acting beta-2 agonists (LAMA/LABA) combinations are amongst moderate-to-severe COPD recommended treatments. This article analyses LAMA/LABA combinations effect on COPD patients exercise capacity and physical activity outcomes.MethodsA systematic review and meta-analysis of double-blind randomized controlled trials comparing LAMA/LABA combinations against monotherapy or placebo was conducted.ResultsSeventeen articles were identified (N = 4041 patients). In endurance shuttle walk test and constant work rate cycle ergometry, LAMA/LABA combinations obtained better results than placebo, but not monotherapy, whereas in 6-min walking test, results favoured LAMA/LABA over monotherapy (four studies), but not over placebo (one study). Moreover, LAMA/LABA combinations obtained better results than placebo in number of steps per day, reduction in percentage of inactive patients and daily activity-related energy expenditure, and better than monotherapy when measuring time spent on ≥ 1.0–1.5, ≥ 2.0 and ≥ 3.0 metabolic equivalents of task activities.ConclusionsLAMA/LABA combinations in COPD patients provided better results than monotherapy or placebo in most exercise capacity and physical activity outcomes.

Induced sputum eosinophilia and pulmonary function tests in ex-smokers with asthma controlled with an inhaled steroid and long-acting beta-agonist therapy.

This study aims to investigate the relationship between induced sputum eosinophilia and pulmonary functions in ex-smoker asthma patients controlled with an ICS/LABA therapy. Asthma patients who are known to use ICS/LABA regularly for at least three months, without an attack in the last month, quit smoking (5-20 pack-years) and have asthma under control (ACT> 20), and concurrent with induced sputum cytology who had spirometry and lung volume measurements were included in the study. Cytology results, induced sputum eosinophil and neutrophil counts, FEV1 (L), FEV1 (%), FVC (L), FVC (%), RV (L), RV (%) and RV/TLC (%) values of all patients were recorded. The relationship between sputum neutrophil and eosinophil count and pulmonary function test parameters was evaluated. Seventeen (68%) of the patients were female, eight (32%) were male, and the mean age was 49.7 ± 13.6 years. The mean sputum eosinophil percentage was 9.4 ± 16.7, and the neutrophil percentage was 71.4 ± 20.5. A positive correlation was found between induced sputum eosinophil percentage values and FEV1 (L) (r= +0.472; p= 0.01) and FVC (L) (r= +0.502; p= 0.01). No correlation was found between the FEV1/FVC%, FEV1%, FVC%, RV (L), RV%, and RV/TLC% values and the percentage of induced sputum eosinophils (p> 0.05). It was observed that controlled asthmatic patients with induced sputum eosinophilia treated with ICS/LABA and who quit smoking had high FVC (L) and FEV1 (L) levels.

An audit to review high risk asthma patients with over-use of short-acting beta-agonist inhalers

Abstract Introduction The UK National Review of Asthma deaths (NRAD)1 has shown that the over-prescribing of Short Acting Beta Agonist’s (SABA) inhalers is a risk factor for exacerbation and death in asthmatic patients. A quality improvement audit was identified as a priority to review practice performance in line with national guidelines.2,3 Aim The aim was to identify patients on the asthma register who were prescribed 12 or more SABA inhalers within the preceding 12 months and investigate any reasons for overuse. Additionally, patients were highlighted for review to optimise management in line with national recommendations2,3. Methods A search run in a GP practice highlighted high-risk patients on the asthma register prescribed 12 or more SABAs in the preceding 12 months. Audit criteria were defined to assess if 100% of patients had a completed annual asthma review. Patients who were not asthmatics or undergoing investigations for a potential diagnosis of chronic obstructive pulmonary disease (COPD) were excluded. Phase 1 of the audit was notes-based data-collection on recent asthma reviews and reasons for potential overuse. In Phase 2, patients were contacted prioritising those overdue a review. During contact, the Asthma Control Test, checking inhaler technique, discussing any reasons for SABA over-use and patient education on their inhalers were all discussed. Patients requiring treatment optimisation or a follow-up review were highlighted for referral to various members of the multidisciplinary team. This audit did not require ethical approval. Results 42 out of 988 patients with asthma were identified as being issued more than 12 SABA’s in the preceding 12 months. 1 patient was excluded due to having a diagnosis of COPD. Out of the remaining 41 patients, 16 patients had already had an up to date annual asthma review prior to the search. 13 patients were contacted and referred to the pharmacist or asthma nurse for a review. As a result of the audit, a total of 29 patients had an asthma review conducted. 12 patients were unable to be contacted and follow-up remains outstanding. A number of themes were highlighted during the audit such as patients using the incorrect dose or inhaler, lack of understanding on how the inhaler worked, requests for spare inhalers, absence/lack of using an inhaled corticosteroid (ICS) and worsening asthma. Discussion/Conclusion The audit successfully identified reasons for SABA overuse and using the multidisciplinary team to educate patients and optimise medication where needed. Following this audit, the practice has reviewed cohorts of patients that are at high risk of exacerbations and implemented quarterly safety searches to highlight these for review on a regular basis. Two further audits were also identified to improve practice in line with updated national guidance; patients prescribed a SABA alone without an ICS and patients prescribed a Long-acting beta-agonist (LABA) alone without an ICS.

Medication Adherence in Medicare-Enrolled Older Adults with Chronic Obstructive Pulmonary Disease before and during the COVID-19 Pandemic.

Medication adherence to controller inhalers was unknown in older Medicare patients with chronic obstructive pulmonary disease (COPD) before and during the pandemic. This study evaluated changes in medication adherence to controller medications and factors associated with high adherence. This retrospective cohort study included older Medicare patients with COPD. The proportion of days covered (PDC) reflected changes in medication adherence from January to July in 2019 and in 2020. Paired t-test evaluated changes in adherence. Logistic regression determined the association of patient characteristics with high adherence (PDC ≥ 80%). Mean adherence decreased (p < 0.001) for long-acting beta-agonists, long-acting muscarinic antagonists, and inhaled corticosteroids in 2020. The percentage of patients with high adherence dropped from 74.4% to 58.1% (p < 0.001). The number of controllers, having ≥3 albuterol fills, and a 90-day supply were associated with high adherence in 2019 and 2020 (p < 0.001). The COVID-19 pandemic may negatively impact medication adherence. Patients with evidence of more severe diseases and a 90-day supply were more likely to adhere to therapy. Healthcare professionals should prioritize prescribing 90-day supplies of medications and monitor drug-related problems as components of pharmacovigilance to enhance adherence to therapies and the desired clinical outcomes among patients with COPD.

Clinical characteristics and drug utilisation patterns in patients with chronic cough: a retrospective cohort study using a Japanese claims database

BackgroundAlthough unmet medical needs for better care of patients with chronic cough exist in Japan, epidemiological information about these patients and their treatments is very limited.ObjectivesTo describe patient characteristics, underlying cough-related diseases and drug utilisation patterns in patients with chronic cough, and their changes over time.MethodsThis large retrospective claims database study enrolled subjects with chronic cough, identified either by a specific diagnostic cough code for chronic cough (Population 1) or by multiple cough-related diagnostic codes spanning > 8 weeks (Population 2). Within Population 2, patients with each of the three most frequent diagnostic cough codes were analysed as subgroups. Patient characteristics, underlying cough-related diseases and utilisation patterns for drugs used for cough were documented at the index date, during the 6-month pre-index period and during the 12-month post-index period.Results6,038 subjects were enrolled in the cohort (Population 1: N = 3,500; Population 2: N = 2,538). The mean age was 43.7 ± 12.2 years and 61.8% were women. The largest cough diagnosis subgroups in Population 2 were ‘other coughs’ (N = 1,444), ‘cough-variant asthma’ (N = 1,026) and ‘atopic/allergic cough’ (N = 105). At the index date, the most frequent underlying cough-related diseases were allergic rhinitis/nasal inflammation (N = 3,132; 51.9%), asthma (N = 2,517; 41.7%) and gastro-esophageal reflux disease (N = 829; 13.7%). At the index date, 4,860 participants (80.5%) were prescribed at least one cough-related treatment. 194 participants (4.0% of medication users) were prescribed central antitussives alone, principally in Population 1, and 2,331 (48.0%) were prescribed expectorants. Other frequently prescribed medications were antiallergic drugs (N = 2,588; 53.3%), antimicrobials (N = 1,627; 34.4%) and inhaled corticosteroids with long-acting beta-agonists (N = 1,404; 28.9%). Over time, cough diagnoses tended to be lost, with only 470 participants in Population 1 retaining a diagnostic code for chronic cough one year later. The frequency of underlying cough-related diseases was stable over time.ConclusionsPatients in this cohort with chronic cough are most frequently identified by a diagnostic cough code for chronic cough, followed by codes for other coughs, cough-variant asthma and atopic cough. Chronic cough frequently presents with an underlying cough-related disease, most frequently allergic rhinitis/nasal inflammation, asthma or GERD. Medication prescription for the underlying cough-related diseases was generally appropriate.

Clinical predictors of treatment response to tiotropium add-on therapy in adult asthmatic patients: From multicenter real-world cohort data in Korea

BackgroundTiotropium, a long-acting muscarinic antagonist, is recommended for add-on therapy to inhaled corticosteroids (ICS)-long-acting beta 2 agonists (LABA) for severe asthma. However, real-world studies on the predictors of response to tiotropium are limited. We investigated the real-world use of tiotropium in asthmatic adult patients in Korea and we identified predictors of positive response to tiotropium add-on. MethodsWe performed a multicenter, retrospective, cohort study using data from the Cohort for Reality and Evolution of Adult Asthma in Korea (COREA). We enrolled asthmatic participants who took ICS-LABA with at least 2 consecutive lung function tests at 3-month intervals. We compared tiotropium users and non-users, as well as tiotropium responders and non-responders to predict positive responses to tiotropium, defined as 1) increase in forced expiratory volume in 1 s (FEV1) ≥ 10% or 100 mL; and 2) increase in asthma control test (ACT) score ≥3 after 3 months of treatment. ResultsThe study included 413 tiotropium users and 1756 tiotropium non-users. Tiotropium users had low baseline lung function and high exacerbation rate, suggesting more severe asthma. Clinical predictors for positive response to tiotropium add-on were 1) positive bronchodilator response (BDR) [odds ratio (OR) = 6.8, 95% confidence interval (CI): 1.6–47.4, P = 0.021] for FEV1 responders; 2) doctor-diagnosed asthma-chronic obstructive pulmonary disease overlap (ACO) [OR = 12.6, 95% CI: 1.8–161.5, P = 0.024], and 3) initial ACT score <20 [OR = 24.1, 95% CI: 5.45–158.8, P < 0.001] for ACT responders. FEV1 responders also showed a longer exacerbation-free period than those with no FEV1 increase (P = 0.014), yielding a hazard ratio for the first asthma exacerbation of 0.5 (95% CI: 0.3–0.9, P = 0.016). ConclusionsThe results of this study suggest that tiotropium add-on for uncontrolled asthma with ICS-LABA would be more effective in patients with positive BDR or ACO. Additionally, an increase in FEV1 following tiotropium may predict a lower risk of asthma exacerbation.

Temporal and geographical variation in low carbon inhaler dispensing in England, 2016 to 2021: an ecological study.

In 2019-2020, four national recommendations were published in the United Kingdom to encourage use of low carbon inhalers. This study aimed to investigate whether these were associated with a change in primary care dispensing in England and to explore associations between geographical variation and clinical commissioning group (CCG) characteristics. Ecological study using aggregated publicly available data. All CCGs in England (March 2016 to February 2021). not applicable. Percentage of low carbon inhalers dispensed. The percentage of low carbon inhalers dispensed was 26.3% in 2020-2021 (of 8.8 million inhalers). This decreased over the study period for short-acting beta-agonist (SABA), inhaled corticosteroid (ICS) and ICS+long-acting beta-agonist (LABA) inhalers. The same trend was seen for LABA and ICS+LABA+long-acting muscarinic antagonist inhalers from 2019. The SABA and ICS classes were less often dispensed as low carbon inhalers (⁓6% versus 35-45%). Interrupted time series analyses found slight increases in low carbon inhaler percentage in the SABA, LABA and ICS classes after April 2019, which were soon erased by the long-term trend. There was also geographical variation, with the north-west, Birmingham and London consistently dispensing more low carbon inhalers. The presence of advice on climate change in CCG formularies/guidelines, the prevalence of asthma and population age profile were associated with significant variation in low carbon inhaler percentage for some classes. The percentage of low carbon inhalers dispensed in England remains low and continues to decrease. Greater use of low carbon inhalers is achievable, but is more likely with locally implemented initiatives.

A new analytic tool for assessing the impact of the US Food and Drug Administration regulatory actions.

Develop and test a flexible, scalable tool using interrupted time series (ITS) analysis to assess the impact of Food and Drug Administration (FDA) regulatory actions on drug use. We applied the tool in the Sentinel Distributed Database to assess the impact of FDA's 2010 drug safety communications (DSC) concerning the safety of long-acting beta2-agonists (LABA) in adult asthma patients. We evaluated changes in LABA use by measuring the initiation of LABA alone and concomitant use of LABA and asthma controller medications (ACM) after the DSCs. The tool generated ITS graphs and used segmented regression to estimate baseline slope, level change, slope change, and absolute and relative changes at up to two user-specified time point (s) after the intervention. We tested the tool and compared our results against prior analyses that used similar measures. Initiation of LABA alone declined among asthma patients aged 18-45 years before FDA DSCs (-0.10% per quarter; 95%CI: -0.11% to -0.09%) and the downward trend continued after. Concomitant use of LABA and ACM was stable before FDA DSCs. After FDA DSCs, there was a small trend decrease of 0.006% per quarter (95% CI, -0.008% to -0.003%). We found similar results among those aged 46-64 years and patients with poorly-controlled asthma. Our results were consistent with previous studies, confirming the performance of the new tool. We developed and tested a reusable ITS tool in real-world databases formatted to the Sentinel Common Data Model that can assess the impact of regulatory actions on drug use.

Derivation of asthma severity from electronic prescription records using British thoracic society treatment steps

Background:Asthma severity is typically assessed through a retrospective assessment of the treatment required to control symptoms and to prevent exacerbations. The joint British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) guidelines encourage a stepwise approach to pharmacotherapy, and as such, current treatment step can be considered as a severity categorisation proxy. Briefly, the steps for adults can be summarised as: no controller therapy (Step 0), low-strength Inhaled Corticosteroids (ICS; Step 1), ICS plus Long-Acting Beta-2 Agonist (LABA; Step 2), medium-dose ICS + LABA (Step 3), and finally either an increase in strength or additional therapies (Step 4). This study aimed to investigate how BTS/SIGN Steps can be estimated from across a large cohort using electronic prescription records, and to describe the incidence of each BTS/SIGN Step in a general population.Methods:There were 41,433,707 prescriptions, for 671,304 individuals, in the Asthma Learning Health System Scottish cohort, between 1/2009 and 3/2017. Days on which an individual had a prescription for at least one asthma controller (preventer) medication were labelled prescription events. A rule-based algorithm was developed for extracting the strength and volume of medication instructed to be taken daily from free-text data fields. Asthma treatment regimens were categorised by the combination of medications prescribed in the 120 days preceding any prescription event and categorised into BTS/SIGN treatment steps.Results:Almost 4.5 million ALHS prescriptions were for asthma controllers. 26% of prescription events had no inhaled corticosteroid prescriptions in the preceding 120 days (Step 0), 16% were assigned to BTS/SIGN Step 1, 7% to Step 2, 21% to Step 3, and 30% to Step 4. The median days spent on a treatment step before a step-down in treatment was 297 days, whereas a step-up only took a median of 134 days.ConclusionWe developed a reproducible methodology enabling researchers to estimate BTS/SIGN asthma treatment steps in population health studies, providing valuable insights into population and patient-specific trajectories, towards improving the management of asthma.

Characteristics of Oral Corticosteroid Users Among Persons with Asthma on GINA Step 3 Therapy and Above: A Cross-Sectional Study in Portuguese Community Pharmacies.

Oral corticosteroids (OCS) are frequently used in asthma management but have an important risk-profile. The aim of the study is to characterize and compare the sociodemographic and clinical characteristics, treatment regimen and asthma control between OCS users and non-users among the population of asthma patients (≥18 years) at GINA step 3 and above treated with a fixed combination of an inhaled corticosteroid and a long-acting beta-agonist (ICS/LABA). Cross-sectional study in Portuguese community pharmacies. Data was collected via paper-based interview delivered at the pharmacy (sociodemographic characteristics and asthma treatment regimen, namely ICS/LABA and OCS utilization), followed by a telephonic interview collecting smoking history, comorbidities, body mass index (BMI), history of exacerbations and asthma-related healthcare resource utilization (HCRU) in the previous 12 months, as well as asthma control using the Control of Allergic Rhinitis and Asthma Test (CARAT®). A total of 347 patients recruited in 98 pharmacies were included in the analysis. Of those, 328 had completed both questionnaires. A quarter of the individuals reported OCS use in the previous 12 months (OCS users), either as add-on therapy (6%) or exacerbation treatment (19%). Patients were mostly females (72%), with an average age of 59.5 years (SD=15.4). OCS users were significantly older and reported more frequently having conjunctivitis (25.9% vs 15.0%), osteoporosis (25.9% vs 13.4%), arthritis (14.6% vs 6.9%), and gastrointestinal disease (16.1% vs 8.1%). OCS users also reported greater urgent HCRU: unscheduled consultations (33.3% vs 9.3%) and emergency department (ED) visits (32.1% vs 12.1%). Both groups presented poor disease control (85.2% of OCS users vs 72.9% of non-OCS users). These results highlight the burden of OCS therapy to asthma patients and the need to improve asthma management, by adopting OCS sparing strategies in this subgroup of patients.

Fractional Exhaled Nitric Oxide Testing: Change in Clinical Management of Asthma, or Chronic Obstructive Pulmonary

Asthma and chronic obstructive pulmonary disease (COPD) are common airway inflammatory conditions that can present in isolation or a combination known as asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). Due to similarities in clinical presentation, differentiating these conditions can be challenging. Fractional exhaled nitric oxide (FeNO) is an endogenous molecule that can be elevated in patients with airway inflammation, particularly asthma. The purpose of this study was to determine if FeNO levels can be used to change pharmacologic management (addition, in patients presenting with asthma, COPD, and ACOS. A retrospective chart review of 250 patients underwent FeNO testing; 93 patients were included in the final analysis with their FeNO levels and medications. Out of 76 patients, 34 were prescribed medications of interest (inhaled corticosteroids (ICS), Inhaled corticosteroids - long-acting beta-agonists (ICS-LABA), anticholinergics (AC) monotherapy or combination therapy). After the FeNO testing, the number of patients on ICS therapy doubled (8 to 16), and the number of patients on ICS -LABA increased by 69.2%. Lastly, the number of patients not on medication of interest, 57.1%, ended up on one after FeNO testing. Our results support the utility of FeNO as a viable test to manage patients with obstructive lung disease.

Efficacy of Combination Therapy in Patients with Stable Coronary Heart Disease with Comorbid Chronic Obstructive Pulmonary Disease

The objective: to analyze the quality of life (QoL) and functional status after combination therapy in patients with stable coronary heart disease (CHD) and comorbid chronic obstructive pulmonary disease (COPD). Materials and methods. The study included 60 men with stable CHD in combination with COPD. The patients were divided into two groups of 30 people, comparable according to the main indicators. Study group (1) received basic treatment with nebivolol, valsartan, eplerenone, acetylsalicylic acid, rosuvastatin for CHD and basic COPD treatment with combination of umeclidinium bromide (a long-acting cholinolytic) and vilanterol (a long-acting beta2-agonist). Patients from Group 2 in addition tj the basic treatment received L-arginine in the form of an infusion of 4.2% 100 ml solution for 10 days, followed by oral administration at a dose of 3 g per day. The duration of treatment was 6 months. Quality of life was evaluated by validated standardized non-specific questionnaire «The 36-Item Short Form Health Survey» (SF-36), a validated specific respiratory questionnaire of St. George’s Hospital – St. George’s Respiratory Questionnaire (SGRQ). The functional state of patients before and after treatment was evaluated by cardiorespiratory test, which included the distance 6-minutes walk test (6MWT) according to the standard method in combination with pulse oximetry (SpO2), calculation of desaturation level (ΔSpO2), recording of electrocardiogram and blood pressure before and after exercise. Results. After the treatment, patients in both groups noted a significant improvement in quality of life across all domains of the SF-36 questionnaire, which includes 36 questions with physical and mental components. Patients from group 2 demonstrated better results of treatment in all indicators of physical functioning, general health and vital activity than patients from group 1. The results of the quality of life evaluation according to the specific respiratory questionnaire SGRQ also showed a significant improvement in patients of both groups. In both groups, the distance of 6MWT significantly increased, the heart rate at rest and after exercise decreased, and the level of desaturation decreased. In group 2, the increase in the distance of 6MWT, the decrease of desaturation level was significantly better than in group 1. Conclusions. Rational combination treatment of patients with stable coronary heart disease (CHD) with comorbid chronic obstructive pulmonary disease (COPD) includes nebivolol, valsartan, eplerenone, acetylsalicylic acid, rosuvastatin and a combination of vilanterol and umeclidinium bromide, contributes to improving the quality of life of patients and their functional status. Addition of L-arginine to the basic combination treatment of patients with CHD and COPD increases the efficacy of therapy and improves cardiohemodynamics. Addition of L-arginine to the treatment complex contributed to the additional improvement of the physical and mental patterns of quality of life and indicators of cardiorespiratory test.

Impact of medications on outcomes in patients with acute myocardial infarction and chronic obstructive pulmonary disease: A nationwide cohort study.

Various inhaled bronchodilators have been associated with cardiovascular safety concerns. This study aimed to investigate the long-term impact of chronic obstructive pulmonary disease (COPD) and the safety of COPD medications in patients after their first acute myocardial infarction (AMI). This nationwide cohort study was conducted using data from the Taiwan National Health Insurance Research Database. Patients hospitalized between 2000 and 2012 with a primary diagnosis of first AMI were included and divided into three cohorts (AMI, ST-elevation myocardial infarction [STEMI], and non-STEMI [NSTEMI]). Each cohort was propensity score matched (1:1) with patients without COPD. A Cox proportional hazards regression model was used to estimate hazard ratios (HRs) with 95% CIs. A total of 186 112 patients with AMI were enrolled, and COPD was diagnosed in 13 065 (7%) patients. Kaplan-Meier curves showed that patients with COPD had a higher mortality risk than those without COPD in all cohorts (AMI, STEMI, and NSTEMI). The HR of mortality in AMI, STEMI, and NSTEMI patients with COPD was 1.12 (95% CI, 1.09-1.14), 1.20 (95% CI, 1.14-1.25), and 1.07 (95% CI, 1.04-1.10), respectively. Short-acting inhaled bronchodilators and corticosteroids increased mortality risk in all three cohorts. However, long-acting inhaled bronchodilators reduced mortality risk in patients with AMI (long-acting beta-agonist [LABA]: HR, 0.87; 95% CI, 0.81-0.94; long-acting muscarinic antagonist [LAMA]: HR, 0.82; 95% CI, 0.69-0.96) and NSTEMI (LABA: HR, 0.89; 95% CI, 0.83-0.97; LAMA: HR, 0.80; 95% CI, 0.68-0.96). This study demonstrated that AMI patients with COPD had higher mortality rates than those without COPD. Using inhaled short-acting bronchodilators and corticosteroids reduced survival, whereas long-acting bronchodilators provided survival benefits in AMI and NSTEMI patients. Therefore, appropriate COPD medication for acute AMI is crucial.

Cost-Effectiveness Analysis of Budesonide/Formoterol and Fluticasone/Salmeterol for Stable Chronic Obstructive Lung Disease

Background: Chronic Obstructive Pulmonary Disease (COPD) is one of the four largest types of non-communicable diseases in the world, requiring long-term and routine treatment. Treatment with the inhalation route is in the form of a dry-powder inhaler (DPI) which is easy to use and carry. Combination of corticosteroid and long-acting beta-2 agonist (LABA) in the form of DPI available in Indonesia are budesonide/formoterol and salmeterol/fluticasone. The purpose was to identify therapy was more cost-effective between budesonide/formoterol than fluticasone/salmeterol in clinical symptoms using COPD assessment test (CAT) value and lung function in FEV1/FVC (Forced Expiratory Volume in First Seconds/Forced Vital Capacity) ratio.Methods: This research study was pre-post design with cost-effectiveness analysis, in outpatient COPD patients in a hospital in Gresik Regency, from October 2019 to January 2020. There were two outcomes of respondents in this study, namely lung function seen from the value of FEV1, and clinical symptoms seen from the value of CAT. The study used hospital perspective.Results: There were 38 respondents involved. Fluticasone/salmeterol therapy was more effective than the budesonide/formoterol group in improving FEV1/FVC ratio, while budesonide/formoterol was more effective than the fluticasone/salmeterol group in improving clinical symptoms by CAT assessment. The average cost effectiveness ratio (ACER) value of lung function between the fluticasone/salmeterol group (IDR.176.465/Liter) was lower than that of budesonide/formoterol (IDR.296.832/Liter). The ACER clinical symptoms value between the fluticasone/salmeterol group (IDR.16,283/score) was smaller than that of budesonide/formoterol (IDR.17,340/score). Conclusion: Fluticasone/salmeterol was more cost-effective than budesonide/formoterol in improving lung function. Meanwhile, for clinical symptoms, fluticasone/salmeterol was trade-off with budesonide/formoterol.

Risk Factors for Lung Function Decline in Pediatric Asthma under Treatment: A Retrospective, Multicenter, Observational Study.

Background: Childhood asthma is a major risk for low lung function in later adulthood, but what factors in asthma are associated with the poor lung function during childhood is not known. Objective: To identify clinical factors in children with asthma associated with low or declining lung function during the treatment. Methods: We enrolled children with asthma who had been treated throughout three age periods, i.e., 6–9, 10–12, and 13–15 years old, at seven specialized hospitals in Japan. Clinical information and lung function measurements were retrieved from the electronic chart systems. To characterize the lung function trajectories during each age period, we evaluated the forced expiratory volume 1 (FEV1) with % predicted values and individual changes by the slope (S) from linear regression. We defined four trajectory patterns: normal (Group N) and low (Group L), showing %FEV1 ≥80% or <80% throughout all three periods; upward (Group U) and downward (Group D), showing S ≥ 0 or S < 0%. Logistic regression analysis was performed to compare factors associated with the unfavorable (D/L) versus favorable (N/U) groups. Results: Among 273 eligible patients, 197 (72%) were classified into Group N (n = 150)/U (n = 47), while 76 (28%) were in Group D (n = 66)/L (n = 10). A history of poor asthma control, long-acting beta2 agonist use, and a lower height Z-score during 13–15 years were associated with an unfavorable outcome (Group D/L). Conversely, inhaled corticosteroid (ICS) use during 10–12 years and high-dose ICS use during 13–15 years were associated with a favorable outcome (Group N/U). Conclusion: We identified several factors that are associated with unfavorable lung function changes in pediatric asthma. Attention should be paid to the possible relationship between yearly changes in lung function and poor asthma control, use of ICS (and its dose) and use of LABA.

Managing chronic obstructive pulmonary disease in primary care: clinical characteristics of patients receiving inhaled corticosteroids

AbstractBackgroundInhaled corticosteroid (ICS) therapy in patients with chronic obstructive pulmonary disease (COPD) has been associated with a variety of unfavourable effects, including increased risk of pneumonia, and is only recommended if specific characteristics are present to ensure patients derive the most benefit.AimThe primary objective was to evaluate the clinical characteristics of patients prescribed ICS therapy for COPD management in two primary care clinics at an academic medical centre. The secondary objectives were to examine provider assessment and barriers to prescribing patterns concordant with guidelines in the ambulatory care setting.MethodA retrospective 24‐month study at two primary care clinics was undertaken at an academic medical centre in Arkansas, United States and focused on adult patients who were prescribed ICS maintenance therapy. Individuals within each clinic were identified by Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) codes indicative of COPD from 1 January 2019 to 31 December 2020. Spirometry was also required to confirm diagnosis.ResultsOf the 189 unique patients identified, 100 were eligible for review of clinical characteristics. All patients received ICS therapy in combination with a long‐acting beta agonist (LABA) with 55% of patients also receiving a long‐acting muscarinic antagonist (LAMA). Furthermore, 32% of patients visited the emergency department or were hospitalised for a COPD exacerbation within the previous year. Approximately 47% and 36% of patients had a history of pneumonia and an eosinophil count &lt;100 cells/mcL respectively. Barriers to guideline adherence were identified through open discussion with providers within each clinic, which included a lack of readily available resources in the clinic setting, suboptimal recognition of clinical tools within the electronic medical record and alternative guideline preferences.ConclusionA small portion of patients evaluated in the study were discovered to have clinical characteristics suggestive of strong ICS benefit as these therapies either lacked efficacy due to low blood eosinophil count or exacerbation rate (80% and 68% respectively), or increased the risk for harm in this population secondary to previous pneumonia diagnosis (47%).