Distribution and outcomes of a phenotype-based approach to guide COPD management: Results from the CHAIN cohort

Rationale: The Spanish guideline for COPD (GesEPOC) recommends COPD treatment according to four clinical phenotypes: non-exacerbator phenotype with either chronic bronchitis or emphysema (NE), asthma-COPD overlap syndrome (ACOS), frequent exacerbator phenotype with emphysema (FEE) or frequent exacerbator phenotype with chronic bronchitis (FECB). However, little is known on the distribution and outcomes of the four suggested phenotypes. Objective: We aimed to determine the distribution of these COPD phenotypes, and their relation with one-year clinical outcomes. Methods: We followed a cohort of well-characterized patients with COPD up to one-year. Baseline characteristics, health status (CAT), BODE index, rate of exacerbations and mortality up to one year of follow-up were compared between the four phenotypes. Results: Overall, 831 stable COPD patients were evaluated. They were distributed as NE, 550 (66.2%); ACOS, 125 (15.0%); FEE, 38 (4.6%); and FECB, 99 (11.9%); additionally 19 (2.3%) COPD patients with frequent exacerbations did not fulfill the criteria for neither FEE nor FECB. At baseline, there were significant differences in symptoms, FEV1 and BODE index (all p<0.05). The FECB phenotype had the highest CAT score (17.1±8.2, p<0.05 compared to the other phenotypes). Frequent exacerbator groups (FEE and FECB) were receiving more pharmacological treatment at baseline, and also experienced more exacerbations the year after (all p<0.05) with no differences in one-year mortality. Most of NE (93%) and half of exacerbators were stable after one year. Conclusions: There is an uneven distribution of COPD phenotypes in stable COPD patients, with significant differences in demographics, patient-centered outcomes and health care resources use

New GOLD classification: Longitudinal data on group assignment

Rationale: Little is known about the longitudinal changes associated with using the 2013 update of the multidimensional GOLD strategy for chronic obstructive pulmonary disease (COPD). Objective: To determine the COPD patient distribution of the new GOLD proposal and evaluate how this classification changes over one year compared with the previous GOLD staging based on spirometry only. Methods: We analyzed data from the CHAIN study, a multicenter observational Spanish cohort of COPD patients who are monitored annually. Categories were defined according to the proposed GOLD: FEV1%, mMRC dyspnea, COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and exacerbations-hospitalizations. One-year follow-up information was available for all variables except CCQ data. Results: At baseline, 828 stable COPD patients were evaluated. On the basis of mMRC dyspnea versus CAT, the patients were distributed as follows: 38.2% vs. 27.2% in group A, 17.6% vs. 28.3% in group B, 15.8% vs. 12.9% in group C, and 28.4% vs. 31.6% in group D. Information was available for 526 patients at one year: 64.2% of patients remained in the same group but groups C and D show different degrees of variability. The annual progression by group was mainly associated with one-year changes in CAT scores (RR, 1.138; 95%CI: 1.074-1.206) and BODE index values (RR, 2.012; 95%CI: 1.487-2.722). Conclusions: In the new GOLD grading classification, the type of tool used to determine the level of symptoms can substantially alter the group assignment. A change in category after one year was associated with longitudinal changes in the CAT and BODE index

Clinical Application of the COPD Assessment Test: Longitudinal Data From the COPD History Assessment in Spain (CHAIN) Cohort

OBJECTIVE: The COPD Assessment Test (CAT) has been proposed for assessing health status in COPD, but little is known about its longitudinal changes. The objective of this study was to evaluate 1-year CAT variability in patients with stable COPD and to relate its variations to changes in other disease markers. METHODS: We evaluated the following variables in smokers with and without COPD at baseline and aft er 1 year: CAT score, age, sex, smoking status, pack-year history, BMI, modified Medical Research Council (mMRC) scale, 6-min walk distance (6MWD), lung function, BODE (BMI, obstruction, dyspnea, exercise capacity) index, hospital admissions, Hospital and Depression Scale, and the Charlson comorbidity index. In patients with COPD, we explored the association of CAT scores and 1-year changes in the studied parameters. R ESULTS: A total of 824 smokers with COPD and 126 without COPD were evaluated at baseline and 441 smokers with COPD and 66 without COPD 1 year later. At 1 year, CAT scores for patients with COPD were similar ( ± 4 points) in 56%, higher in 27%, and lower in 17%. Of note, mMRC scale scores were similar ( ± 1 point) in 46% of patients, worse in 36%, and better in 18% at 1 year. One-year CAT changes were best predicted by changes in mMRC scale scores ( β -coefficient, 0.47; P<, .001). Similar results were found for CAT and mMRC scale score in smokers without COPD. CONCLUSIONS: One-year longitudinal data show variability in CAT scores among patients with stable COPD similar to mMRC scale score, which is the best predictor of 1-year CAT changes. Further longitudinal studies should confirm long-term CAT variability and its clinical applicability. © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS.The authors have reported to CHEST the follow ing conflicts of interest: Dr de Torres received fees for speaking activities for GlaxoSmithKline plc, AstraZeneca, Novartis AG, Merck Sharp & Dohme Corp, and Takeda Pharmaceuticals International GmbH and received consultancy fees for participating on advisory boards for Takeda Pharmaceuticals International GmbH and Novartis AG between 2010 and 2013. Dr Martinez-Gonzalez received fees for speaking activities for Almirall, SA; AstraZeneca; Boehringer Ingelheim GmbH; Pfi zer Inc; GlaxoSmithKline plc; and Chiesi Farmaceutici SpA between 2010 and 2013. Dr de Lucas-Ramos received fees for speaking activities for Almirall, SA; Boehringer Ingelheim GmbH; Takeda Pharmaceuticals International GmbH; and GlaxoSmithKline plc and received grants from Almirall, SA, and Foundation Vital Aire between 2010 and 2013. Dr Cosio received fees for speaking activities for Almirall, SA; Takeda Pharmaceuticals International GmbH; The Menarini Group; Boehringer Ingelheim GmbH; Pfizer Inc; GlaxoSmithKline plc; and Chiesi Farmaceutici SpA between 2010 and 2013. Dr Peces-Barba received fees for speaking activities for Almirall, SA; Takeda Pharmaceuticals International GmbH; Novartis AG; Boehringer Ingelheim GmbH; AstraZeneca; Esteve; GlaxoSmithKline plc, and Chiesi Farmaceutici SpA; received consultancy fees for participating in advisory boards of Takeda Pharmaceuticals International GmbH, Novartis AG, and Ferrer Internacional; and received grants from GlaxoSmithKline plc between 2010 and 2013. Dr Solanes-García received fees for speaking activities for Esteve; AstraZeneca; Th e Menarini Group; Boehringer Ingelheim GmbH; Pfizer Inc; GlaxoSmithKline plc, Biodatos Investigación SL, and Chiesi Farmaceutici SpA between 2010 and 2013. Dr Agüero Balbin received fees for speaking activities for Almirall, SA; AstraZeneca; Novartis AG; Boehringer Ingelheim GmbH; Takeda Pharmaceuticals International GmbH; GlaxoSmithKline plc; and Chiesi Farmaceutici SpA between 2010 and 2013. Dr de Diego-Damia received fees for speaking activities for Boehringer Ingelheim GmbH, AstraZeneca, Pfizer Inc, Merck Sharp & Dohme Corp, GlaxoSmithKline plc, and Chiesi Farmaceutici SpA between 2010 and 2013. Dr Alfageme Michavila received fees for speaking activities for Almirall, SA; Boehringer Ingelheim GmbH; and Pfizer Inc between 2010 and 2013. Dr Irigaray received fees for speaking activities for Novartis AG, Takeda Pharmaceuticals International GmbH, GlaxoSmithKline plc, and Chiesi Farmaceutici SpA between 2010 and 2013. Dr Llunell Casanovas received fees for speaking activities for AstraZeneca, Eli Lilly and Co, and Chiesi Farmaceutici SpA between 2010 and 2013. Dr Galdiz Iturri received fees for speaking activities for Almirall, SA; Novartis AG; AstraZeneca; Boehringer Ingelheim GmbH; GlaxoSmithKline plc; and Chiesi Farmaceutici SpA between 2010 and 2013. Dr Soler-Cataluña participated in speaking activities, on an industry advisory committee, or with other related activities sponsored by Almirall, SA; AstraZeneca; Boehringer Ingelheim GmbH; Pfizer Inc; Ferrer Internacional; GlaxoSmithKline plc; Takeda Pharmaceuticals International GmbH; Merck Sharp & Dohme Corp; Novartis AG; and Grupo Uriach between 2010 and 2013. Dr Soriano received grants from GlaxoSmithKline plc in 2011 and Chiesi Farmaceutici SpA in 2012 through his home institution and participated in speaking activities, on an industry advisory committee, or with other related activities sponsored by Almirall, SA; Boehringer Ingelheim GmbH; Pfizer Inc; Chiesi Farmaceutici SpA; GlaxoSmithKline plc; and Novartis AG between 2010 and 2013. Dr Casanova participated in speaking activities for Almirall, SA; Takeda Pharmaceuticals International GmbH; Chiesi Farmaceutici SpA; GlaxoSmithKline plc; and Novartis AG between 2010 and 2013. Drs Marin, Mir-Viladrich, CalleRubio, Feu-Collado, Balcells, Marín Royo, and Lopez-Campos have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article