Long-acting inhaled therapy (beta-agonists, anticholinergics and steroids) for COPD: a network meta-analysis

Kew, Kayleigh M; Dias, Sofia; Cates, Christopher J

doi:10.1002/14651858.cd010844.pub2

Cited by 111 publications

(54 citation statements)

References 331 publications

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“…23,24 Our finding that newly identified cases tended to have mild or moderate airflow obstruction was in keeping with previous case-finding studies 10 and newly case-found patients were generally less severe than patients newly diagnosed in primary care. 25 Nevertheless, in accordance with our model, the majority of new cases could potentially benefit from inhalers, 26,27 self-management support, 28 smoking cessation 29 and vaccinations. 30 A substantial proportion (27%) also had significant breathlessness with potential to benefit from pulmonary rehabilitation.…”

supporting

confidence: 70%

Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial

Jordan

Adab

Sitch

et al. 2016

The Lancet Respiratory Medicine

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Word count: 4222 3 RESEARCH IN CONTEXT Evidence before this studyIt is widely accepted that COPD is substantially under-diagnosed worldwide. Mass population screening with spirometry is not recommended although early identification of undiagnosed patients with clinical disease is generally supported because COPD has significant patient, healthcare and societal burden which could potentially be lessened through timely diagnosis. A comprehensive systematic review of the effectiveness of case-finding studies, published in 2015, revealed 39 published studies but few included a comparator arm. Only one RCT has compared a case-finding approach with routine care to identify clinically significant COPD, identifying that opportunistic administration of a screening questionnaire at practice visits was twice as effective as routine care, but non-comparative studies suggest that high yields could be achieved from active case finding with mailed questionnaires to high risk patients. No previous trial has compared the clinical and costeffectiveness of alternative approaches to case-finding in a real-life primary care setting. Added value of this studyTargetCOPD is the first randomised controlled trial to evaluate the effectiveness and costeffectiveness of active case-finding for COPD compared with opportunistic case finding and to compare these approaches with routine care. Among 54 general practices, we found that when targeting ever smokers aged 40-79 years, active case finding was more than twice as effective as opportunistic case finding, and that together, these targeted approaches were over seven times as effective as current routine care. Active case finding was also more cost-effective than opportunistic case finding. Implications of all the available evidenceIn a real-life setting, active case-finding comprising an initial mailed questionnaire followed by spirometry should be recommended for identifying undiagnosed COPD in primary care. An important proportion of these previously undiagnosed patients have significant breathlessness and earlier identification and management with effective treatments including inhalers and pulmonary rehabilitation has the potential to improve their health. This trial provides the evidence for guidelines which was previously lacking. 4 SUMMARY Background

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supporting

confidence: 70%

Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial

Jordan

Adab

Sitch

et al. 2016

The Lancet Respiratory Medicine

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“…This effect may also be present in COPD airways, given that ~30% of CFTR function remains [15, 137, 161]. Similarly, inhaled 2 adrenergic receptor agonists are a mainstay of COPD treatment, and they are thought to relieve the airway obstruction by inducing smooth muscle relaxation, as seen in asthmatic patients [216]. However, these agonists also activate CFTR [217].…”

Section: Treatment For Cftr Diminution and Mucus Dehydration In Copdmentioning

confidence: 99%

Airway hydration and COPD

Ghosh

Boucher

Tarran

2015

Cell. Mol. Life Sci.

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Chronic obstructive pulmonary disease (COPD) is one of the prevalent causes of worldwide mortality and encompasses two major clinical phenotypes, i.e., chronic bronchitis (CB) and emphysema. The most common cause of COPD is chronic tobacco inhalation. Research focused on the chronic bronchitic phenotype of COPD has identified several pathological processes that drive disease initiation and progression. For example, the lung’s mucociliary clearance (MCC) system performs the critical task of clearing inhaled pathogens and toxic materials from the lung. MCC efficiency is dependent on: (i) the ability of apical plasma membrane ion channels such as the cystic fibrosis transmembrane conductance regulator (CFTR) and the epithelial Na+ channel (ENaC) to maintain airway hydration; (ii) ciliary beating; and, (iii) appropriate rates of mucin secretion. Each of these components is impaired in CB and likely contributes to the mucus stasis/accumulation seen in CB patients. This review highlights the cellular components responsible for maintaining MCC and how this process is disrupted following tobacco exposure and with CB. We shall also discuss existing therapeutic strategies for the treatment of chronic bronchitis and how components of the MCC can be used as biomarkers for the evaluation of tobacco or tobacco-like-product exposure.

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“…Lastly, a new Cochrane network meta-analysis demonstrated that within the available evidence, ICS/LABA shows the biggest improvements compared with placebo, followed by LAMA or LABA, and then ICS alone, for both the SGRQ and FEV1 values [22]. They did not analyse other clinically important outcomes such as mortality and exacerbations, quoting two other meta-analyses on these instead: Dong et al [23] found that ICS/LABA had the lowest risk of mortality when compared with placebo, tiotropium or LABA only, and a 2009 meta-analysis looking at exacerbations only, which found that neither ICS or ICS/LABA was more effective than each other or LAMA [24].…”

Section: Stable Copd: Inhaled Corticosteroidsmentioning

confidence: 99%

Tailoring of corticosteroids in COPD management

Coster

Jones

2014

Curr Respir Care Rep

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This literature review updates the reader on the new studies regarding steroid therapy over the last year in stable COPD and in exacerbations. In stable COPD, we critique the 2011 update and 2013 revision of the GOLD guidelines, discuss why combining inhaled corticosteroids (ICS) with long-acting beta-agonists (LABA) (ICS/LABA) is preferable over LABA alone and review the literature for intraclass differences, finding that the evidence does not clearly support superiority of any particular ICS/LABA. We also address other comparisons against ICS/LABA, including triple therapy. We briefly review which type of inhaler should be chosen. For exacerbations, we report the REDUCE trial findings favouring a 5-day course of systemic steroids, and other trials addressing which steroid and route to use, including in an intensive care setting. Lastly, the future lies in new anti-inflammatories and re-phenotyping the heterogeneous amalgamation of COPD. A Spanish guideline recommends distinguishing steroid-responsive eosinophilic exacerbators from other phenotypes.

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Long-acting inhaled therapy (beta-agonists, anticholinergics and steroids) for COPD: a network meta-analysis

Cited by 111 publications

References 331 publications

Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial

Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial

Airway hydration and COPD

Tailoring of corticosteroids in COPD management

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