Simplifying COPD Treatment 2023 PDF

Simplifying COPD Treatment A RESEARCH REVIEW™ SPEAKER SERIES Making Education Easy About the speaker Associate Professor Robert Young Dr Young is a General Physician at Auckland City Hospital. He is a medical graduate of the University of Otago and was awarded a Commonwealth Scholarship which ena...

Simplifying COPD Treatment A RESEARCH REVIEW™ SPEAKER SERIES Making Education Easy About the speaker Associate Professor Robert Young Dr Young is a General Physician at Auckland City Hospital. He is a medical graduate of the University of Otago and was awarded a Commonwealth Scholarship which enabled him to graduate from the University of Oxford with a PhD in Molecular Genetics. He has been a Consultant Physician in the Department of Medicine, Auckland City Hospital for the last 25 years and is jointly appointed as Associate Professor in the Faculties of Health and Medical Sciences and the School of Biological Sciences at the University of Auckland. Currently he lectures to medical students and post-graduate science students. His research and clinical interests focus on the primary prevention and early diagnosis of the smoking-related respiratory diseases COPD and lung cancer. He has been the first to show that COPD and lung cancer are linked at a molecular genetic level through overlapping pathogenetic pathways which are activated by smoking in susceptible smokers. ABOUT RESEARCH REVIEW Research Review is an independent medical publishing organisation producing electronic publications in a wide variety of specialist areas. A Research Review Speaker Series is a summary of a speaking engagement by a medical expert. It is made available to health professionals via e-mail or website download to Research Review subscribers or by physical distribution by Research Review or third parties. Research Review has no control over the content of these presentations, which has been developed and presented by the featured expert. Research Review is not responsible for any inaccuracies or errors of fact made by, or opinions of, the speaker. 2023 This publication summarises key points from a breakfast symposium presented by Associate Professor Robert Young at the Rotorua General Practice Conference & Medical Exhibition (GP CME) in June 2023. It discusses the burden of chronic obstructive pulmonary disease (COPD), in particular breathlessness and exacerbations, and the importance of screening for symptoms. Up-to-date recommendations for pharmacological management of COPD are summarised, including new advice from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Evidence for the use of dual and triple therapy in COPD is then presented. Sponsorship for the symposium was provided by GlaxoSmithKline (GSK). Burden of COPD Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally, accounting for more than 3 million deaths every year.1 In New Zealand, 15% of the population aged >45 years has COPD, which is approximately 200,000 people.2 More than 6000 new cases of COPD are diagnosed in New Zealand each year, with Māori and Pasifika disproportionately affected.2,3 New Zealand has the fourth highest rate of hospital admissions in adults with asthma and COPD among OECD member countries.4 As a disease, COPD remains under-diagnosed and under-treated.5 In addition to the risks of hospitalisation and mortality, patients with COPD exhibit a clinically meaningful decline in health status, health-related quality of life and prognosis associated with depression and anxiety, poor sleep and lost work days.6-8 Breathlessness has a significant impact on daily activities.9,10 In a pan-European study of 2441 patients, COPD symptoms affected going up and down stairs in 83%, performing heavy household duties in 57%, going shopping in 43% and doing sport or hobbies in 36%.10 Breathlessness in COPD is linked with a downward spiral of deteriorating health status, which starts as the patient avoids physical activity after experiencing dyspnoea.11,12 As the patient becomes more sedentary, physiological deconditioning aggravates their dyspnoea, and further reduces activity.11,12 Exacerbations are an important feature of COPD, and become more frequent and severe as lung function declines.13 They are the most common reason for hospitalisation in patients with COPD,14 and are associated with an increased risk of mortality.15 Exacerbations are a major contribution to the economic burden associated with COPD.16,17 In a Canadian cohort study that followed more than 70,000 patients with COPD for 17 years, 50% of patients died within 4 years of their first hospitalisation for a COPD exacerbation.15 Each severe exacerbation in patients with COPD increases the risk of another event or death, with subsequent exacerbations increasing in severity.15,18 Diagnosis and assessment A diagnosis of COPD should be considered in any individual aged >40 years who presents with breathlessness, wheeze, cough or sputum production, particularly those with a history of smoking.9 The 5-level modified Medical Research Council (mMRC) Dyspnoea Scale may be used to screen for breathlessness (see Table 1).9 Patients with a mMRC score ≥2 should undergo further investigation.5 Grade Symptom complex 0 I only get breathless with strenuous exercise 1 I get short of breath when hurrying on level ground or walking up a slight hill 2 On level ground, I walk slower than other people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace on the level 3 I stop for breath after walking about 100 metres or after a few minutes on level ground 4 I am too breathless to leave the house or I am breathless when dressing or undressing Table 1. Modified Medical Research Council (mMRC) Dyspnoea Scale.9 www.researchreview.co.nz a RESEARCH REVIEW™ publication 1 ™ NZ COPDREVIEW GUIDELINES A RESEARCH SPEAKER SERIES Simplifying COPD Treatment Other causes for breathlessness, such as heart disease and obesity, should also 9 be considered. Exercise2:tolerance can be usedtest to assess breathlessness Appendix COPDtests assessment (CAT). severity and disease progression over time.9 Patients should be asked about sputum production with coughing. Chronic cough Name: Date: with sputum production for ≥3 months per year for 2 consecutive years indicates chronic bronchitis, and is common in patients with COPD.5 Chronic sputum production mucus plugging withAssessment lower lung function and greater How isand your COPD? Takeare thelinked COPD Test (CAT) decline forced expiratory 1 second (FEV1) measure in patients with COPD.5 This in questionnaire will help youvolume and your in healthcare professional the impact Obstructive Pulmonary Disease) is having on your wellbeing and daily life. The COPD COPD(Chronic Assessment Test (CAT) is an 8-item questionnaire that can be used Your answers and test score, can be used by you and your healthcare professional to help to measure overall ofsymptomatic of COPD, as well as response to improve thethe management your COPD and impact get the greatest benefit from treatment. treatment (see Figure 1).9 A score of 10 or more is the cut-point for considering For each item below, place a mark (X) in the box that best describes you currently. Be sure regular maintenance therapy for question. symptoms.5 to only select one response for each TM COPD Assessment Test Example: I am very happy 0 1 2 3 4 5 COPD diagnosis should be confirmed by spirometry; persistent airflow limitation is indicated by a post-bronchodilator FEV1 to forced vital capacity (FVC) ratio <0.70.9 Post-bronchodilator improvement in FEV1 in patients with COPD is <200 ml.9 In contrast, patients with asthma/COPD overlap (ACO) have variable airflow limitation and show a post-bronchodilator improvement in FEV1 of >400 ml.9 Recommendations for pharmacological management The aims of pharmacological treatment for COPD are to reduce symptoms and prevent exacerbations, and treatment should be individualised based on breathlessness and exacerbation frequency.9 Updated GOLD guidelines I am sad POINTS I never cough 0 1 2 3 4 5 I cough all the time I have no phlegm (mucus) in my chest at all 0 1 2 3 4 5 My chest is full of phlegm (mucus) My chest does not feel tight at all 0 1 2 3 4 5 My chest feels very tight When I walk up a hill or one flight of stairs I am not breathless 0 1 2 3 4 5 When I walk up a hill or one flight of stairs I am very breathless I am not limited doing any activities at home 0 1 2 3 4 5 I am very limited doing activities at home I am confident leaving my home despite my lung condition 0 1 2 3 4 5 I am not at all confident leaving my home because of my lung condition I sleep soundly 0 1 2 3 4 5 I don’t sleep soundly because of my lung condition I have lots of energy 0 1 2 3 4 5 I have no energy at all TOTAL SCORE GSK Cat.indd 1 6/08/12 9 11:09 AM Figure 1. Chronic Obstructive Pulmonary Disease Assessment Test (CAT). NZMJ 19 February 2021, Vol 134 No 1530 25 ISSN 1175-8716 © NZMA www.nzma.org.nz/journal Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 recommendations for pharmacological management of COPD follow the ABE assessment tool, as shown in Figure 2.5 This tool considers the number and severity of exacerbations, as well as mMRC and CAT scores.5 In a simplification from GOLD 2022 recommendations, patient groups C and D have been merged into a single group (E), to recognise the clinical relevance of exacerbations, independent of the level of symptoms.5,19 GOLD now recommends dual bronchodilation with a long-acting muscarinic antagonist (LAMA) plus a long-acting beta2 agonist (LABA) as the cornerstone of treatment for the majority of symptomatic patients with COPD.5 Monotherapy should only be used in patients with few symptoms and a low risk of exacerbations (group A).5 These patients can be treated with either a short-acting or long-acting bronchodilator, however a longacting bronchodilator is preferred except for those with very occasional breathlessness.5 In New Zealand, PHARMAC Special Authority criteria for LAMA/LABA requires that patients are first stabilised on LAMA monotherapy, however, no mandatory time period for stabilisation is specified.20 Use of an inhaled corticosteroid (ICS) plus LABA in COPD is not encouraged by GOLD.5 If there is an indication for an ICS, then triple therapy with an ICS plus LAMA plus LABA is preferred, as this has been shown to be superior to ICS/LABA.5 GOLD guidelines state that patients with COPD who have concomitant asthma should be treated like patients with asthma, in which case use of an ICS is mandatory.5 GOLD 2022 ≥2 moderate exacerbations or ≥1 leading to hospitalisation 0 or 1 moderate exacerbations (not leading to hospital admission) Group C LAMA Group A A bronchodilator mMRC 0–1 CAT <10 GOLD 2023 Group D LAMA or LAMA + LABA or ICS + LABA Group B A long-acting bronchodilator (LABA or LAMA) mMRC ≥2 CAT ≥10 Simplified approach ≥2 moderate exacerbations or ≥1 leading to hospitalisation 0 or 1 moderate exacerbations (not leading to hospital admission) Group E LABA + LAMA Consider LABA+LAMA+ICS if blood eos ≥300 cells/μL Group A A bronchodilator Group B LABA + LAMA mMRC 0–1, CAT <10 mMRC ≥2, CAT ≥10 Figure 2. Comparison of GOLD 2022 and 2023 recommendations for pharmacological management of COPD.5,19 CAT, COPD Assessment Tool; COPD, chronic obstructive pulmonary disease; eos, eosinophils; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroid; LABA, long-acting beta2 agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnoea Scale. New Zealand Research Review subscribers can claim CPD/CME points for time spent reading our reviews from a wide range of local medical and nursing colleges. Find out more on our CPD page. www.researchreview.co.nz a RESEARCH REVIEW™ publication 2 A RESEARCH REVIEW™ SPEAKER SERIES Simplifying COPD Treatment NZ COPD guidelines The NZ COPD 2021 guidelines state that shortacting beta2 agonists (SABA) and short-acting muscarinic antagonists (SAMA) can be taken asneeded to provide temporary relief of breathlessness, either alone or in combination.9 However, patients with ongoing breathlessness should receive regular maintenance therapy with a long-acting bronchodilator, and a LAMA is the preferred choice.9 Patients receiving LAMA therapy should not continue to use a SAMA (e.g. ipratropium bromide in Atrovent21 or Duolin22).9 If breathlessness persists despite LAMA monotherapy, patients should be transitioned to maximal bronchodilation with a LAMA/LABA.9 A LAMA/LABA is also preferred for most patients with frequent exacerbations, but those with eosinophilia (serum eosinophils > 0.3 x 109 cells/L) may benefit from ICS/LABA.9 Patients may be transitioned to triple therapy with ICS plus LAMA plus LABA if they continue to experience ≥2 exacerbations per year.9 Patients with severe or recurrent exacerbations may benefit from direct escalation to dual or triple therapy, without stepwise up-titration.9 While single inhaler triple therapy is not yet available in New Zealand, patients may use an ICS/LABA inhaler in combination with a LAMA inhaler. Maintenance therapy for patients with ACO usually consists of ICS/LABA in a single inhaler, with the addition of LAMA if needed.9 However, patients with ACO have largely been excluded from clinical trials, meaning that treatment recommendations are based on expert opinion only.9 Maintenance therapy recommendations for patients with COPD, as published in the NZ COPD 2021 guidelines, are summarised in Table 2.9 LABAs LAMAs LAMA/LABA combinations ICS/LABA combinations When treating Start with If needed, move on to COPD without frequent exacerbations LAMA LABA/LAMA COPD with frequent exacerbations LAMA LABA/LAMA (consider ICS/LABA for eosinophilia) then LABA/LAMA/ICS Asthma/COPD overlap ICS/LABA ICS/LABA plus LAMA Table 2. Recommendations for maintenance therapy in patients with COPD from the NZ COPD 2021 guidelines.9 COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting beta2 agonist; LAMA, long-acting muscarinic antagonist. Suggested approach for maintenance therapy Taking into account the new recommendations published by GOLD, and current recommendations from the NZ COPD 2021 guidelines, a slightly modified approach to maintenance therapy for patients with COPD is suggested in Table 3.5,9 When treating Start with If needed, move on to COPD without frequent exacerbations LAMA Earlier for the patient with exertional breathlessness LABA/LAMA COPD with frequent exacerbations LAMA LABA/LAMA or LABA/LAMA/ICS (for eosinophilia) Asthma/COPD overlap ICS/LABA ICS/LABA plus LAMA Table 3. Suggested approach for maintenance therapy in patients with COPD.5,9 COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting beta2 agonist; LAMA, long-acting muscarinic antagonist. Maintenance therapies for COPD that are currently funded in New Zealand are listed in Table 4.23-40 Agent Tradename Subsidy23 Formoterol fumarate Oxis Turbuhaler24 Indacaterol Onbrez Breezhaler Fully subsidised Salmeterol Serevent;26 Serevent Accuhaler27 Fully subsidised Glycopyronium Seebri Breezhaler Fully subsidised with written endorsement Tiotropium Spiriva;29 Spiriva Respimat30 Fully subsidised with written endorsement Umeclidinium Incruse Ellipta Fully subsidised with written endorsement Glycopyrronium + indacaterol Ultibro Breezhaler32 Fully subsidised with Special Authority Tiotropium + olodaterol Spiolto Respimat Fully subsidised with Special Authority Umeclidinium + vilanterol Anoro Ellipta34 Budesonide + formoterol Duoresp Spiromax; Symbicort Turbuhaler; Vannair Fully subsidised Fluticasone propionate + salmeterol Seretide;38 Seretide Accuhaler39 Fully subsidised Fluticasone furoate + vilanterol Breo Ellipta Fully subsidised Partially subsidised 25 28 31 33 Fully subsidised with Special Authority 35 36 37 40 Table 4. Maintenance therapies for COPD that are funded in New Zealand.23-40 COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting beta2 agonist; LAMA, long-acting muscarinic antagonist. www.researchreview.co.nz a RESEARCH REVIEW™ publication 3 A RESEARCH REVIEW™ SPEAKER SERIES Simplifying COPD Treatment Evidence for dual and triple therapy Triple therapy* vs ICS/LABA Dual bronchodilation vs monotherapy In the extension phase of the FULFIL trial, which involved 430 patients with COPD who remained on blinded treatment for 52 weeks, triple therapy with the ICS/LAMA/ LABA combination fluticasone furoate + umeclidinium + vilanterol led to a 44% relative reduction in the annual rate of moderate/severe exacerbations compared with the ICS/LABA combination budesonide + formoterol (absolute exacerbation rate 0.20 vs 0.36, respectively; p = 0.006).44 Common adverse events occurred at a similar frequency in the triple therapy and budesonide + formoterol groups (11% vs 10% for nasopharyngitis and 8% vs 10% for headache, respectively), as did the frequency of pneumonia (1.9% vs 1.8%, respectively) and serious adverse events (10.0% vs 12.7%, respectively).44 In a US real-world study of 689 patients with spirometry-confirmed COPD, more than 50% still experienced breathlessness despite bronchodilator monotherapy, regardless of disease severity.41 A network meta-analysis of 23 trials involving more than 27,000 patients with COPD found dual bronchodilation with a LAMA/LABA to be more effective than both LAMA and LABA monotherapy at improving lung function, reducing breathlessness, improving quality of life and reducing exacerbations.42 In the network meta-analysis, the safety profile of LAMA/LABA therapy was similar to monotherapy with either a LAMA or LABA.42 Triple therapy* vs LAMA/LABA In the IMPACT trial of 10,355 patients with COPD treated for 52 weeks, triple therapy with fluticasone furoate + umeclidinium + vilanterol led to a 34% relative reduction in the annual rate of hospitalised exacerbations compared with the LAMA/LABA dual combination of umeclidinium + vilanterol (absolute exacerbation rate 0.13 vs 0.19, respectively; p <0.001).45 Adverse events occurred with a similar frequency in the triple therapy and umeclidinium + vilanterol groups (serious events 22% vs 23%, respectively, including pneumonia in 4% vs 3%, respectively).45 The overall rate of clinician-diagnosed pneumonia was higher in the triple therapy vs umeclidinium + vilanterol group (8% vs 5%, respectively).45 In the same trial, fluticasone furoate + umeclidinium + vilanterol also reduced the rate of all-cause mortality by 42% vs umeclidinium + vilanterol (hazard ratio 0.58; 95% CI 0.380.88; p = 0.011; see Figure 3).46 This was the first trial to prospectively show a reduction in all-cause mortality with any pharmacologic therapy for COPD.46 Comparison of LAMA/LABA combinations Probability of on-treatment all-cause mortality (%) In a randomised, crossover study of 236 symptomatic patients with COPD who were not receiving ICS, trough FEV1 at week 8 was improved from baseline to a significantly greater extent with the LAMA/LABA combination umeclidinium/vilanterol than tiotropium/ olodaterol (least squares mean difference between groups 52 ml; 95% CI 28-77 ml; p<0.001).43 The frequencies of common adverse events were similar between the umeclidinium/vilanterol and tiotropium/olodaterol groups (5% vs 6% for viral upper respiratory tract infections, 3% vs 3% for upper respiratory tract infections and <1% vs 2% for sinusitis, respectively), as was the frequency of serious adverse events (1% vs <1%, respectively).43 2.2 LAMA + LABA (n=2070) 2.0 ICS + LABA + LAMA (n=4141) 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0 28 56 84 112 140 168 196 224 252 280 308 336 364 Time to event (days) Figure 3. All-cause mortality with fluticasone furoate + umeclidinium + vilanterol vs umeclidinium + vilanterol in the IMPACT trial of patients with COPD.46 COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting beta2 agonist; LAMA, long-acting muscarinic antagonist. *Triple therapy studies were conducted with a single inhaler containing fluticasone furoate, umeclidinium and vilanterol. Single inhaler triple therapy is not yet available in New Zealand, but a combination of the funded inhalers fluticasone furoate/vilanterol and umeclidinium provide the same molecules. www.researchreview.co.nz a RESEARCH REVIEW™ publication 4 A RESEARCH REVIEW™ SPEAKER SERIES Simplifying COPD Treatment Prompt vs delayed initiation of triple therapy* in the study who received triple therapy ≤30 days after a moderate/severe exacerbation had a 28% lower risk of exacerbation at 12 months compared with those who received therapy within 31-180 days (hazard ratio 0.72; 95% CI 0.52-0.83; p=0.001; see Figure 4).47 A recently published real-world retrospective cohort study of 1904 patients with COPD found that prompt initiation of triple therapy (fluticasone furoate + umeclidinium + vilanterol) after exacerbation prolonged the time to subsequent exacerbation by nearly 6 months compared with delayed initiation.47 Patients Probability of oexacerbation (%) 100 80 48.3% 30.5% 40 49.8% 42.7% 33.9% 20 0 Prompt initiation Delayed initiation 23.7% 0 59.4% 54.2% 60 3 6 9 12 Months Figure 4. Exacerbations with early vs delayed initiation of fluticasone furoate + umeclidinium + vilanterol in a real-world study of patients with COPD.47 COPD, chronic obstructive pulmonary disease. *Triple therapy studies were conducted with a single inhaler containing fluticasone furoate, umeclidinium and vilanterol. Single inhaler triple therapy is not yet available in New Zealand, but a combination of the funded inhalers fluticasone furoate/vilanterol and umeclidinium provide the same molecules. TAKE-HOME MESSAGES • Screen at-risk patients for exertional breathlessness (mMRC score) and overall symptomatic impact (CAT score), and confirm COPD diagnosis with spirometry9 • Dual bronchodilation with a LAMA/LABA is now recommended by GOLD as the cornerstone of treatment for the majority of symptomatic patients with COPD5 • Use of ICS should be limited to patients with ACO, persistently elevated eosinophils or those with break-through exacerbations on dual bronchodilation with a LAMA/LABA9 • Triple therapy with an ICS plus LAMA plus LABA is more effective at reducing exacerbations than dual therapy with either ICS/LABA or LAMA/LABA44-45 • A recent trial has shown that triple therapy reduces all-cause mortality when compared with dual (LAMA/LABA) therapy46 Respiratory RESEARCH REVIEW This review features key medical articles from global respiratory journals with commentary from Professor Lutz Beckert. The Review covers topics such as COPD, pulmonary embolism, venous thromboembolism, emphysema, chronic bronchitis, cystic fibrosis, non-small cell lung cancer, obstructive sleep apnoea, corticosteroids and nebulisers. Respiratory tory RespiraREV IEW In this issue: RESEARCH Making Education We offer over 50 different Reviews in various clinical areas. Subscription costs nothing – go to www.researchreview.co.nz Easy ™ Easy Child maltreat ment, anxiety depress and ™ ion, and asthma Long-term effect of asthma on adult obesity Welcome to this of asthma. We Issue 206 issue – 2023 of Respiratory are ready for colleagues. My Research Review local setting allows a more ‘normal’ year, although to share some on the topic of the internation me the benefit of time to stay it has not been a good start, particularly for al asthma research. up-to-date with In July 2022, our Auckland my reading, and Thank you for – 2023 206GINA (the Global Initiative I am privileged your readership Issue prevention to be able . for Asthma) released . The 225-page report is more and guidance Physical activity a reference; however, their updated global strategy on asthma. 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In on informative ychiatric (Eur Respir J 2022;60:2 this issue towereduce thethe new ATS/ERS guidelines its key information in this eventJan 2023). risk strategies 9, the in patients on ponder online (Eur Respir 103179). particularly J 2022;60:2 AIR (anti-the ‘European Respiratory on performing spirometry Immunol Pract; published 3–30 years provided a aged short summary focussing a difference’. 101585). (Respirator Society guidelines A brief review using AIR, and making by PHARMAC has of some of the for the diagnosis y Research Review Respir Med: ‘Advancement He Ako Hiringa supported and Pacific peoples: ‘Asthma: thinking SMART, roundup Canofairway Lancetobstruction PICO questions of asthma in Māori follows. in asthma and measured adults’ in the tenth anniversary burden of asthma in Airway on ‘Innovation by spirometry focusses strongly Yes, spirometry its bodies: Med 2023;11:15–7). In the– series therapy alsoautoanti and help diagnose inhalerrecommen is strongly inflammatory reliever) determi ICS-formoterol asthma in adults decade’of(Lancet Respir Can peakofexpiratory ded. in the pastnants 79). with episodic/ch asthma highlight the poor availability colleagues of asthma management and severity flow variability ronic symptoms (Eur Respir J 2022;60:21031 testing help diagnose Mortimer, Helen Reddel ? countries: case for change’– No, peak expiratoryResearch Review its treatment’, Kevin CRTH2inantagon asthma in adults low and middle income (Respiratory flow variability spirometry ism and with measuring FeNO of asthma in adults’as a primary test to on performingCan impact: ‘Asthma management respons diagnose asthma episodic/chronic suggestive new ATS/ERS guidelines the diagnosis help diagnose rhinoviru guidelines–for reflectedeontothe symptoms? asthma in adults is not recommen Yes, FeNO can s infection Respiratory Society In December 2022 we in asthma be part of the ded. follows. we ponder the ‘European diagnostic workup.with episodic/chronic suggestive some of the PICO questionsCan combining FeNO, Issue 204). In this issue symptoms? 85). 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Remission Our colleagues Currently, asthma withbowel disease, and define Can bronchialcaesare of curing borrow the remission antests should be the diagnosis delivery it for asthma: asthma is not is ainlogical lung capacity help – Yes, these challenge possible, and remission no symptoms, paradigm shift. and residual volume/totalto include remissions no exacerbations The authors call may be the more airway conductance (and not fewer specific for Ulcerativ guidelines are measuring realistic and achievable some of the newer Can exacerbations) e colitis-related to adopt remission as the endpoint. tools available. suggestive symptoms? as the lung workup. The take-home diseases episodic/chronic In this ‘Asthma in the diagnostic context, the review ‘Treatable traits’, macrolides standard and for trials message is that is the article we have sufficient eosinophils and its treatment’ – No, not currently recommended and by the remission on ‘Innovation in asthma: evidence immune redundanc David Jackson and Ian Pavord biological therapies from mouseborrow articles in the series 83). 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Lam on ‘How I see and of local medical Review subscribers in Respirology range www.researchr and nursing colleges. can claim CPD/CME as ‘A Passion to Serve (APSR) could be read points Find out more eview.co.nz comments and feedback. on our CPD page. for time spent reading our reviews from Thank you for your readership, a wide Kind regards, Beckert Lutz Professor a RESEAR z CH REVIEW [email protected] ™ publicat from a wide ion reading our reviews points for time spent can claim CPD/CME 1 Review subscribers out more on our CPD page. Find New Zealand Research and nursing colleges. range of local medical publication a RESEARCH REVIEW™ 1 Welcome In this issue: anxiety and Child maltreatment, depression, and asthma asthma on Long-term effect of adult obesity sleep Physical activity reduces disturbances in asthma Low-dose OCSs in asthma associate with increased morbidity and mortality bushfire Prolonged Australian with smoke exposure in women asthma atric LTRAs and neuropsychi aged event risk in patients 3–30 years www.researchreview.co.nz RESEARCH REVIEW Making Educa tion Airway autoantibodies: severity determinants of asthma and CRTH2 antagonism infection response to rhinovirus in asthma of Environmental impact inhalers t SABA-free asthma managemen AIR with maintenance and CT of larynx for diagnosing vocal cord dysfunction a RESEARCH REVIEW™ publication Childhood asthma risk caesarean delivery after d lung Ulcerative colitis-relate diseases Impact of insulin resistance asthma on lung function and treatment response this issue Abbreviations used in y reliever AIR = anti-inflammator nitric oxide FeNO = fraction of exhaled corticosteroid ICS/OCS = inhaled/oral ratio IRR = incidence rate receptor antagonist LTRA = leukotriene β-agonist SABA = short-acting 5 A RESEARCH REVIEW™ SPEAKER SERIES Simplifying COPD Treatment REFERENCES 1. 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Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2023 report). Available at: https://goldcopd.org/2023gold-report-2/ [Accessed June 2023]. 6. Spencer S, Jones PW; GLOBE Study Group. Time course of recovery of health status following an infective exacerbation of chronic bronchitis. Thorax. 2003 Jul;58(7):589-93. 7. Miravitlles M, Ribera A. Understanding the impact of symptoms on the burden of COPD. Respir Res. 2017 Apr 21;18(1):67. 8. Patel JG, Coutinho AD, Lunacsek OE, Dalal AA. COPD affects worker productivity and health care costs. Int J Chron Obstruct Pulmon Dis. 2018 Jul 30;13:2301-2311. 9. Hancox RJ, Jones S, Baggott C, et al. New Zealand COPD Guidelines: Quick Reference Guide. N Z Med J. 2021 Feb 19;134(1530):76-110. 10. Kessler R, Partridge MR, Miravitlles M, et al. Symptom variability in patients with severe COPD: a pan-European cross-sectional study. Eur Respir J. 2011 Feb;37(2):264-72. 11. Reardon JZ, Lareau SC, ZuWallack R. Functional status and quality of life in chronic obstructive pulmonary disease. Am J Med. 2006 Oct;119(10 Suppl 1):32-7. 12. ZuWallack R. How are you doing? What are you doing? Differing perspectives in the assessment of individuals with COPD. COPD. 2007 Sep;4(3):293-7. 13. Hurst JR, Vestbo J, Anzueto A; Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010 Sep 16;363(12):1128-38. 14. Mapel DW, Roberts MH. New clinical insights into chronic obstructive pulmonary disease and their implications for pharmacoeconomic analyses. Pharmacoeconomics. 2012 Oct 1;30(10):869-85. 15. Suissa S, Dell’Aniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality. Thorax. 2012 Nov;67(11):957-63. 16. Pasquale MK, Sun SX, Song F, et al. Impact of exacerbations on health care cost and resource utilization in chronic obstructive pulmonary disease patients with chronic bronchitis from a predominantly Medicare population. Int J Chron Obstruct Pulmon Dis. 2012;7:757-64. 17. Yu AP, Yang H, Wu EQ, et al. Incremental third-party costs associated with COPD exacerbations: a retrospective claims analysis. J Med Econ. 2011;14(3):315-23. 18. Pavord ID, Jones PW, Burgel PR, Rabe KF. Exacerbations of COPD. Int J Chron Obstruct Pulmon Dis. 2016 Feb 19;11 Spec Iss(Spec Iss):21-30. 19. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2022 report). Available at: https://staging.goldcopd. org/2022-gold-reports-2/ [Accessed June 2023]. 20. PHARMAC. Special Authority – long-acting muscarinic antagonists with long-acting beta-adrenoceptor agonists. Available at: https://schedule.pharmac.govt.nz/2023/09/01/SA1584.pdf [Accessed September 2023]. 21. Medsafe. New Zealand Data Sheet. Atrovent. Available at: https://www.medsafe.govt.nz/profs/datasheet/a/ AtroventHFAinh.pdf [Accessed June 2023]. 22. Medsafe. New Zealand Data Sheet. Duolin. Available at: https://www.medsafe.govt.nz/profs/datasheet/d/ duolinhfainh.pdf [Accessed June 2023]. 23. PHARMAC. Pharmaceutical Schedule - September 2023. Available at: https://schedule.pharmac.govt.nz/ ScheduleOnline.php [Accessed September 2023]. 24. Medsafe. New Zealand Data Sheet. Oxis Turbuhaler. Available at: https://www.medsafe.govt.nz/profs/ datasheet/o/Oxisturbuhaler.pdf [Accessed June 2023]. 25. Medsafe. New Zealand Data Sheet. Onbrez Breezhaler. Available at: https://www.medsafe.govt.nz/profs/ datasheet/o/onbrezcap.pdf [Accessed June 2023]. 26. Medsafe. New Zealand Data Sheet. Serevent. Available at: https://www.medsafe.govt.nz/profs/datasheet/s/ SereventCFC-freeinh.pdf [Accessed June 2023]. 27. Medsafe. New Zealand Data Sheet. Serevent Accuhaler. Available at: https://www.medsafe.govt.nz/profs/ datasheet/s/Seretideacchal.pdf [Accessed June 2023]. 28. Medsafe. New Zealand Data Sheet. Seebri Breezhaler. Available at: https://www.medsafe.govt.nz/profs/ datasheet/s/seebricap.pdf [Accessed June 2023]. 29. Medsafe. New Zealand Data Sheet. Spiriva. Available at: https://www.medsafe.govt.nz/profs/datasheet/s/ spirivacap.pdf [Accessed June 2023]. 30. Medsafe. New Zealand Data Sheet. Spiriva Respimat. Available at: https://www.medsafe.govt.nz/profs/ Datasheet/s/Spirivarespimat.pdf [Accessed June 2023]. 31. Medsafe. New Zealand Data Sheet. Incruse Ellipta. Available at: https://www.medsafe.govt.nz/profs/ Datasheet/i/incruseelliptainhal.pdf [Accessed June 2023]. 32. Medsafe. New Zealand Data Sheet. Ultibro Breezhaler. Available at: https://www.medsafe.govt.nz/profs/ Datasheet/u/ultibrocap.pdf [Accessed June 2023]. 33. Medsafe. New Zealand Data Sheet. Spiolto Respimat. Available at: https://www.medsafe.govt.nz/profs/ Datasheet/s/SpioltoRespimatinh.pdf [Accessed June 2023]. 34. Medsafe. New Zealand Data Sheet. Anoro Ellipta. Available at: https://www.medsafe.govt.nz/profs/Datasheet/a/ anoroelliptapowder.pdf [Accessed June 2023]. 35. Medsafe. New Zealand Data Sheet. Duoresp Spiromax. Available at: https://www.medsafe.govt.nz/profs/ Datasheet/d/DuoRespinh.pdf [Accessed June 2023]. 36. Medsafe. New Zealand Data Sheet. Symbicort Turbuhaler. Available at: https://www.medsafe.govt.nz/profs/ datasheet/s/symbicortinh.pdf [Accessed June 2023]. 37. Medsafe. New Zealand Data Sheet. Vannair. Available at: https://www.medsafe.govt.nz/profs/Datasheet/v/ Vannairinh.pdf [Accessed June 2023]. 38. Medsafe. New Zealand Data Sheet. Seretide. Available at: https://www.medsafe.govt.nz/profs/datasheet/s/ Seretideinh.pdf [Accessed June 2023]. 39. Medsafe. New Zealand Data Sheet. Seretide Accuhaler. Available at: https://www.medsafe.govt.nz/profs/ Datasheet/s/Seretideacchal.pdf [Accessed June 2023]. 40. Medsafe. New Zealand Data Sheet. Breo Ellipta. Available at: https://www.medsafe.govt.nz/profs/datasheet/b/ breoelliptainhalation.pdf [Accessed June 2023]. 41. Dransfield MT, Bailey W, Crater G, et al. Disease severity and symptoms among patients receiving monotherapy for COPD. Prim Care Respir J. 2011 Mar;20(1):46-53. 42. Oba Y, Sarva ST, Dias S. Efficacy and safety of long-acting β-agonist/long-acting muscarinic antagonist combinations in COPD: a network meta-analysis. Thorax. 2016 Jan;71(1):15-25. 43. Feldman GJ, Sousa AR, Lipson DA, et al. Comparative Efficacy of Once-Daily Umeclidinium/Vilanterol and Tiotropium/Olodaterol Therapy in Symptomatic Chronic Obstructive Pulmonary Disease: A Randomized Study. Adv Ther. 2017 Nov;34(11):2518-2533. 44. Lipson DA, Barnacle H, Birk R, et al. FULFIL Trial: Once-Daily Triple Therapy for Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2017 Aug 15;196(4):438-446. 45. Lipson DA, Barnhart F, Brealey N; IMPACT Investigators. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med. 2018 May 3;378(18):1671-1680. 46. Lipson DA, Crim C, Criner GJ, et al. Reduction in All-Cause Mortality with Fluticasone Furoate/Umeclidinium/ Vilanterol in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2020 Jun 15;201(12):1508-1516. 47. Mannino D, Bogart M, Germain G, et al. Benefit of Prompt versus Delayed Use of Single-Inhaler Fluticasone Furoate/Umeclidinium/Vilanterol (FF/UMEC/VI) Following a COPD Exacerbation. Int J Chron Obstruct Pulmon Dis. 2022 Mar 5;17:491-504. Incruse Ellipta (umeclidinium bromide 62.5mcg) is a prescription medicine for the regular treatment of COPD. Precautions: Not recommended for use in patients with asthma or for relief of acute symptoms or an acute exacerbation. Use with caution in patients with severe cardiovascular disease, narrow-angle glaucoma or urinary retention. Paradoxical bronchospasm may occur. Before prescribing please review the data sheet at www.medsafe.govt.nz for information on dosage, contraindications, precautions, interactions and adverse effects. Anoro Ellipta (umeclidinium [as bromide] 62.5 mcg, vilanterol [as trifenatate] 25 mcg inhaler) is a prescription medicine for the regular treatment of COPD. Precautions: Not recommended for use in patients with asthma or for relief of acute symptoms or an acute exacerbation. Use with care when coadministering with strong CYP3A4 inhibitors (e.g. ketoconazole) and in patients with severe cardiovascular disease, narrow-angle glaucoma or urinary retention. Paradoxical bronchospasm may occur. Before prescribing please review the data sheet at www.medsafe.govt.nz for information on dosage, contraindications, precautions, interactions and adverse effects. Breo Ellipta (fluticasone furoate 100mcg/vilanterol trifenatate 25mcg) is a prescription medicine for the regular treatment of asthma in adults and adolescents aged 12 years and older and for the regular treatment of COPD in adults with a FEV1<70% predicted normal in patients with an exacerbation history. Before prescribing please review the data sheet for information on dosage, contraindications, precautions, interactions and adverse effects. The data sheet is available at www.medsafe.govt.nz. A separate reliever inhaler may be required. Breo Ellipta is not for the relief of acute symptoms. Seretide (fluticasone propionate/salmeterol xinafoate, available as metered dose inhaler (MDI) 50/25, 125/25, 250/25 mcg per actuation and Accuhaler 100/50 or 250/50 mcg per actuation) is a prescription medicine for the regular treatment of asthma in adults, adolescents and children aged 4 years and over, where use of a combination product (bronchodilator and inhaled corticosteroid) is appropriate. Seretide is also indicated for the symptomatic treatment of adult patients with moderate to severe COPD (prebronchodilator FEV1<60% predicted normal), who have significant symptoms despite bronchodilator therapy. Warnings and Precautions: Not to be initiated in patients during an exacerbation, or if they have unstable or acutely deteriorating asthma. Not for relief of acute symptoms. Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. Paradoxical bronchospasm may occur after dosing, inhaler/accuhaler should be discontinued and patient assessed. Do not discontinue abruptly due to risk of exacerbation. Use carefully when co-administering strong CYP3A4 inhibitors (e.g. ketoconazole) and with caution in patients with pulmonary tuberculosis, thyrotoxicosis, pre-existing cardiovascular disease, patients predisposed to low levels of serum potassium and patients with diabetes mellitus. Before prescribing Seretide, please review the data sheets for information on dosage, contraindications, precautions, interactions and adverse effects. The data sheets are available at www.medsafe.govt.nz. Trademarks are owned by or licensed to the GSK group of companies. ©2023 GSK group companies or its licensor. Incruse Ellipta, Anoro Ellipta and Breo Ellipta were developed in collaboration with Innoviva Inc. Marketed by GlaxoSmithKline NZ Limited, Auckland. Adverse events involving GlaxoSmithKline products should be reported to GSK Medical Information on 0800 808 500. TAPS DA2301VL-PM-NZ-UCV-OGM-230001 Date of Approval: 10 2023 Date of Expiry: 10 2025 Before prescribing any of the prescription medications mentioned in this article please consult the full Product Information. The Data Sheets for Oxis Turbuhaler, Onbrez Breezhaler, Seebri Breezhaler, Serevent, Serevent Accuhaler, Spiriva Handihaler, Spiriva Respimat, Ultibro Breezhaler, Spiolto Respimat, DuoResp Spiromax, Symbicort Turbuhaler and Vannair are available from www.medsafe.govt.nz. Trademarks are owned by their respective owners. Treatment decisions based on these data are the full responsibility of the prescribing physician. www.researchreview.co.nz © 2023 RESEARCH REVIEW a RESEARCH REVIEW™ publication 6