When to use single-inhaler triple therapy in COPD: a practical approach for primary care health care professionals

S Gaduzo,1 V McGovern,2 J Roberts,3 JE Scullion,4 D Singh5 1Stockport NHS Foundation Trust, Stockport, UK; 2Belfast Trust, Belfast, UK; 3Salford Royal NHS Foundation Trust, Salford, UK; 4University Hospitals of Leicester, Leicester, UK; 5Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospital Trust, Manchester, UK Abstract: While single-inhaler triple therapy (SITT) devices were not available when the Global Initiative for Chronic Obstructive Lung Disease strategy and National Institute for Health and Care Excellence guidelines were developed, two devices are now available in the UK. This paper offers practical, patient-focused advice to optimize placement of SITT in the management of COPD. A survey of UK health care professionals (HCPs) identified issues around, and attitudes toward, SITT, which informed a multidisciplinary expert panel’s discussions. The survey confirmed the need to clarify the place of SITT in COPD management. The panel suggested three criteria, any one of which identifies a high-risk patient where escalation to triple therapy from monotherapy or double combination treatment is appropriate: 1) at least two exacerbations treated with oral corticosteroids, antibiotics, or both in the previous year; 2) at least one severe exacerbation that required hospital admission in the previous year; 3) one exacerbation a year on a repeated basis for 2 consecutive years. Appropriate non-pharmacological management is essential for all patients and should be considered before stepping up treatment. Regular review is essential. During each review, HCPs should consider stepping treatment up or down. If patients exacerbate despite adhering to triple therapy, an individualized approach should be considered if the inhaled corticosteroid (ICS) confers benefit or causes side effects. In this situation, the blood eosinophil count could aid decision making. ICSs should be continued when the history suggests that asthma overlaps with COPD. Training, counseling, and education should be individualized. HCPs should consider referral: 1) when there is limited response to treatment and persistent exacerbations; 2) where there is diagnostic uncertainty or suspected comorbidity; 3) whenever they feel “out of their depth.” Overall, the panel concurred that when used correctly, SITT has the potential to improve adherence, symptom control, and quality of life, and reduce exacerbations. Studies using real-world evidence need to confirm these benefits. Keywords: maintenance therapy, routine care, treatment step-up, inhalers, guideline

Criação

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Community metabolomics in environmental microbiology

Evidence from 16S rRNA gene sequences indicates that as yet uncultured microorganisms represent the vast majority of organisms in most environments on earth. However, since many species cannot be cultured within a laboratory setting, these communities are mostly unstudied and consequently there has been little insight into the genetics, physiology and biochemistry of their members. The new field of community metabolomics is about to change this scenario. In the same way as metagenomics indicates the analyses of all DNA from a given sample, community metabolomics looks at the entirety of the thousands of naturally occurring metabolites from the meta-population of a sample of a given environment such as soil or water, and perhaps even air. In this chapter we outline how this new field has recently been applied to generate new insights into these unexplored areas of the bacterial realm in the fields of environmental science and technology, within natural, laboratory and even industrial, settings. Potential future applications in this area are also discussed. Keyword