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Treatment choices in COPD: guideline variance may be driven by patients’ phenotype
There are an increasing number of maintenance therapies available for COPD. Adherence to Global initiative on chronic Obstructive Lung Disease (GOLD) guidelines by physicians has been shown to be poor but it is not clear if this variance can be explained by the clinical characteristics of the patient. Roche and colleagues (Respiratory Research 2019;20:189) investigated how clinical characteristics may influence physician choice of COPD treatment using an observational cohort design. The French COLIBRI project database was used to identify 1171 COPD patients with complete datasets from a total of 4160 available records. Patient’s maintenance COPD treatment was divided into A: no COPD treatment or short-acting bronchodilator(s) only; B: one long-acting bronchodilator (long-acting β agonist; LABA or long-acting muscarinic antagonist; LAMA); C: LABA+LAMA; D: LABA or LAMA+inhaled corticosteroid (ICS); E: triple therapy (LABA+LAMA+ICS). There were discrepancies in treatment choice with surprisingly few patients prescribed a short-acting bronchodilator (34% of the total cohort: 15.4% of GOLD A, 29.5% of GOLD B, 17.9% of GOLD C, 51.4% of GOLD D), and 15% of patients having no inhaled treatments (short-acting or long-acting). ICSs were given in 24.5% of GOLD A and 37.6% of GOLD B patients despite not being indicated in current guidelines. Statistical models showed exacerbation history to be associated with triple therapy and ICS prescription. Interestingly, worse lung function was associated with increased likelihood of maintenance therapy in all groups despite the move away from forced expiratory volume in one second (FEV1) to guide ICS prescribing decisions. The authors conclude that although the study confirms low rates of adherence to prescribing guidelines for COPD, escalation of therapy may be determined by ongoing exacerbations and patient symptom load; however, it is less clear if they modify these factors.
ICSs may reduce rate of decline of FEV1 in COPD irrespective of blood eosinophilia
The role of ICSs in COPD maintenance therapy is controversial. Despite widespread use of ICS, there are significant risks of therapy. Whittaker and colleagues (IJCOPD 2019;14:1063) aimed to identify if there is a subgroup of COPD patients with a greater response to ICS to provide rationale for more targeted therapy. A primary care population of 26 675 COPD patients were identified using a clinical practice research datalink and were stratified into high and low blood eosinophil counts (EOS) using a cut-off of 150 cell/µL. Rate of change in FEV1 was used as a measure of disease progression. Patients treated with ICS showed a slowed rate of decline in FEV1 compared with those without ICS therapy (−12.6 mL/year compared with −21.1 mL/year p=0.001), irrespective of EOS level. When split, high EOS patients improved from −20.8 to −13.7 mL/year with ICS use (p=0.016) and low EOS showed improvement from −21.7 to −10.2 mL/year with ICS use (p=0.008). Data from patients who initiated ICS during the study period indicated an improvement in FEV1 change from −21.2 to +4.2 mL/year (p<0.0001) irrespective of EOS. Rate of change of FEV1 in patients with high EOS was +12.2 mL/year in those initiating ICS during the study compared with −20.8 mL/year in those remaining without ICS therapy (p<0.001). The low EOS subgroup did not show significant change (ICS −15.7 mL/year, no-ICS −21.3 mL/year; p=0.632). Interestingly, patients on ICS were more likely to have a preceding diagnosis of asthma, more frequent exacerbations and more severe dyspnoea. Despite the possible confounders inherent to observational data, this study highlights that EOS may not be the best biomarker for ICS use in COPD.
Bronchial thermoplasty in UK clinical practice
Bronchial thermoplasty (BT) is a novel treatment for airways disease with ongoing uncertainty regarding its role in the management of asthma. Burn and colleagues (BMJ Open 2019;9:e026742) used a multicentre cohort study to assess long-term efficacy and safety of BT. Data from the UK severe asthma registry provided baseline characteristics prior to BT (BTBL) and 12-month (FU12) and 24-month (FU24) follow-up outcomes. Of the 133 patients receiving BT on the registry 86 had suitable data for analysis. There was a 0.75 increase in mean Asthma Quality of Life Questionnaire (minimum clinically important difference ≥0.5) at FU12 (n=28, p=0.0003) and 1.0 fewer hospital admissions per year at FU24 compared with preprocedure (n=26, p<0.0001). A responder analysis was conducted but a clear phenotype could not be identified. The safety evaluation identified 18.9% of BT procedures and 44.5% of patients were affected by ≥1 adverse event; however, the majority were anticipated and minor. Although lacking a control group the data provided insight into current BT practice in the UK with a treatment effect similar to that reported in clinical trials.
Lung cancer patient views on chemotherapy tolerability alters following treatment
Chemotherapy regimens have various toxicity profiles which may affect treatment choice, patient tolerance and ultimately treatment success. Islam and colleagues (BMC Cancer 2019;19:835) aimed to ascertain patient preferences before and after treatment experiences. This US prospective, observational, longitudinal cohort study recorded advanced non-small cell lung cancer patients’ (n=235) rankings of side effects by desire to avoid and length of time willing to tolerate both before and after treatment experience. They found that breathlessness, bleeding and fatigue were top side effects to avoid, with fatigue moving from third to first after treatment experience. Although no patient characteristics were associated with tolerance length, nearly half of patient changed their responses after their experience highlighting the need for reviewing patient preference during treatment. Of note to clinicians, patients with lower educational attainment and poorer socioeconomic status where more likely to be treated with chemotherapy agents with a side effect profile they wished to avoid.
Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.