Tiotropium Respimat® in asthma: a double-blind, randomised, dose-ranging study in adult patients with moderate asthma

BACKGROUND: Tiotropium, a once-daily long-acting anticholinergic bronchodilator, when administered via Respimat® SoftMist™ inhaler (tiotropium Respimat®) significantly reduces the risk of severe exacerbations and improves lung function in patients with severe persistent asthma that is not fully controlled despite using inhaled corticosteroids (ICS) and long-acting β(2)-agonists. To further explore the dose–response curve in asthma, we investigated the efficacy and safety of three different doses of tiotropium Respimat® as add-on to ICS in symptomatic patients with moderate persistent asthma. METHODS: In this randomised, double-blind, placebo-controlled, four-way crossover study, patients were randomised to tiotropium Respimat® 5 μg, 2.5 μg or 1.25 μg or placebo Respimat®, once daily in the evening. Each treatment was administered for 4 weeks, without washout between treatment periods. Eligibility criteria included ≥60% and ≤90% of predicted normal forced expiratory volume in 1 second (FEV(1)) and seven-question Asthma Control Questionnaire mean score of ≥1.5. Patients were required to continue maintenance treatment with stable medium-dose ICS for at least 4 weeks prior to and during the treatment period. Long-acting β(2)-agonists were not permitted during the treatment phase. The primary efficacy end point was peak FEV(1) measured within 3 hours after dosing (peak FEV(1(0-3h))) at the end of each 4-week period, analysed as a response (change from study baseline). RESULTS: In total, 149 patients were randomised and 141 completed the study. Statistically significant improvements in peak FEV(1(0-3h)) response were observed with each tiotropium Respimat® dose versus placebo (all P < 0.0001). The largest difference from placebo was with tiotropium Respimat® 5 μg (188 mL). Trough FEV(1) and FEV(1) area under the curve (AUC)((0-3h)) responses were greater with each tiotropium Respimat® dose than with placebo (all P < 0.0001), and both were greatest with 5 μg. Peak forced vital capacity (FVC)((0-3h)), trough FVC and FVC AUC((0-3h)) responses, versus placebo, were greatest with tiotropium Respimat® 5 μg (P < 0.0001, P = 0.0012 and P < 0.0001, respectively). Incidence of adverse events was comparable between placebo and all tiotropium Respimat® groups. CONCLUSIONS: Once-daily tiotropium Respimat® add-on to medium-dose ICS improves lung function in symptomatic patients with moderate asthma. Overall, improvements were largest with tiotropium Respimat® 5 μg. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01233284

tiotropium reduces airflow obstruction in asthma patients independent of body mass index

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Comparative Responses in Lung Function Measurements with Tiotropium in Adolescents and Adults, and Across Asthma Severities:A Post Hoc Analysis

INTRODUCTION: Airway obstruction is usually assessed by measuring forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF). This post hoc study investigated comparative responses of lung function measurements in adults and adolescents (full analysis set, N = 3873) following treatment with tiotropium Respimat®. METHODS: Lung function outcomes were analysed from five phase III trials in adults (≥ 18 years) with symptomatic severe, moderate and mild asthma (PrimoTinA-asthma®, MezzoTinA-asthma® and GraziaTinA-asthma®, respectively), and one phase III trial in adolescents (12-17 years) with symptomatic moderate asthma (RubaTinA-asthma®). Changes from baseline versus placebo in FEV1, FVC, PEF and FEV1/FVC ratio with tiotropium 5 µg or 2.5 µg added to at least stable inhaled corticosteroids at week 24 (week 12 in GraziaTinA-asthma) were analysed. RESULTS: All lung function measures improved in all studies with tiotropium 5 µg (mean change from baseline versus placebo), including peak FEV1 (110-185 mL), peak FVC (57-95 mL) and morning PEF (15.8-25.6 L/min). Changes in adolescents were smaller than those in adults, and were statistically significant primarily for FEV1 and PEF, but not for FVC. CONCLUSION: Consistent improvements were seen across all lung function measures with the addition of tiotropium to other asthma treatments in adults across all severities, whereas the improvements with tiotropium in adolescents primarily impacted measures of flow rather than lung volume. This may reflect less pronounced airway remodelling and air trapping in adolescents with asthma versus adults

Routine laboratory parameters to support decision on parenteral nutrition in palliative care

IntroductionParenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN.MethodsThe laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time.ResultsThe final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0).DiscussionThe decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN

Organic matter cycling along geochemical, geomorphic and disturbance gradients in forests and cropland of the African Tropics – Project TropSOC Database Version 1.0

The African Tropics are hotspots of modern-day land-use change and are, at the same time, of great relevance for the cycling of carbon (C) and nutrients between plants, soils and the atmosphere. However, the consequences of land conversion on biogeochemical cycles are still largely unknown as they are not studied in a landscape context that defines the geomorphic, geochemically and pedological framework in which biological processes take place. Thus, the response of tropical soils to disturbance by erosion and land conversion is one of the great uncertainties in assessing the carrying capacity of tropical landscapes to grow food for future generations and in predicting greenhouse gas fluxes (GHG) from soils to the atmosphere and, hence, future earth system dynamics. Here, we describe version 1.0 of an open access database created as part of the project &ldquo;Tropical soil organic carbon dynamics along erosional disturbance gradients in relation to variability in soil geochemistry and land use&rdquo; (TropSOC). TropSOC v1.0 contains spatial and temporal explicit data on soil, vegetation, environmental properties and land management collected from 136 pristine tropical forest and cropland plots between 2017 and 2020 as part of several monitoring and sampling campaigns in the Eastern Congo Basin and the East African Rift Valley System. The results of several laboratory experiments focusing on soil microbial activity, C cycling and C stabilization in soils complement the dataset to deliver one of the first landscape scale datasets to study the linkages and feedbacks between geology, geomorphology and pedogenesis as controls on biogeochemical cycles in a variety of natural and managed systems in the African Tropics. The hierarchical and interdisciplinary structure of the TropSOC database allows for linking a wide range of parameters and observations on soil and vegetation dynamics along with other supporting information that may also be measured at one or more levels of the hierarchy. TropSOC&rsquo;s data marks a significant contribution to improve our understanding of the fate of biogeochemical cycles in dynamic and diverse tropical African (agro-)ecosystems. TropSOC v1.0 can be accessed through the supplementary material provided as part of this manuscript or as a separate download via the websites of the Congo Biogeochemistry observatory and the GFZ data repository where version updates to the database will be provided as the project develops.</p

A randomised controlled trial of tiotropium in adolescents with severe symptomatic asthma

We present results from the first phase III trial of once-daily tiotropium add-on to inhaled corticosteroids (ICS) plus one or more controller therapies in adolescents with severe symptomatic asthma.In this double-blind, parallel-group trial (NCT01277523), 392 patients aged 12-17\u2005years were randomised to receive once-daily tiotropium 5\u2005\ub5g or 2.5\u2005\ub5g, or placebo, as an add-on to ICS plus other controller therapies over 12\u2005weeks. The primary and key secondary end-points were change from baseline (response) in peak forced expiratory volume in 1\u2005s (FEV1) within 3\u2005h post-dosing (FEV1(0-3h)) and trough FEV1, respectively, after 12\u2005weeks of treatment.Tiotropium 5\u2005\ub5g provided numerical improvements in peak FEV1(0-3h) response, compared with placebo (90\u2005mL; p=0.104), and significant improvements were observed with tiotropium 2.5\u2005\ub5g (111\u2005mL; p=0.046). Numerical improvements in trough FEV1 response and asthma control were observed with both tiotropium doses, compared with placebo. The safety and tolerability of tiotropium were comparable with those of placebo.Once-daily tiotropium Respimat add-on to ICS plus one or more controller therapies in adolescents with severe symptomatic asthma was well tolerated. The primary end-point of efficacy was not met, although positive trends for improvements in lung function and asthma control were observed

Kidney Function Worsening Is Linked to Parenteral-Nutrition-Dependent Survival in Palliative Care Patients

Background. Parenteral nutrition (PN) is frequently administered in palliative care patients suffering from cachexia. The evidence regarding the use of PN in terminally ill patients is scarce. Routine laboratory parameters might help to decide whether to start or forgo PN, which could decrease overtreatment at the end of life. Kidney failure was frequently associated with survival. However, a relation between kidney function parameters and parenteral nutrition has not been observed thus far. The aim of this retrospective cohort study was to analyze kidney function parameters in palliative care patients under PN, as well as the relation between these parameters and overall survival. Methods. Patients who were admitted to the Department of Palliative Medicine at the Medical University of Vienna were screened for PN treatment. Whether kidney function parameters at baseline or their dynamics over the course of two weeks were associated with survival was assessed with descriptive and interferential statistics. Results. In total, 113 of 443 palliative care patients were administered parenteral nutrition for the first time. The overall survival (OS) for all patients with increased kidney function parameters at baseline was lower (creatinine: hazard ratio (HR) = 1.808, p &lt; 0.001; urea: HR = 1.033, p &lt; 0.001; uric acid HR = 1.055, p = 0.015). No significant increase in creatinine blood levels was observed in the first 2 weeks after the initiation of PN when compared to the non-PN group (p = 0.86). However, if creatinine blood levels increased within the PN group, lower overall survival was found (HR = 2.046, p = 0.007). Conclusion. Increased kidney function parameters, such as creatinine, urea and uric acid, might be used as negative prognostic markers in palliative care patients under PN. Moreover, an increase in creatinine during the administration of parenteral nutrition in the first 2 weeks is linked to worse outcomes. These findings may help future studies to establish objective markers for clinicians to determine whether to start or end PN in palliative cancer patients and decrease potential overtreatment at the end of life

What Makes a Good Palliative Care Physician? A Qualitative Study about the Patient’s Expectations and Needs when Being Admitted to a Palliative Care Unit

<div><p>Objective</p><p>The aims of the study were to examine a) patients’ knowledge of palliative care, b) patients’ expectations and needs when being admitted to a palliative care unit, and c) patient’s concept of a good palliative care physician.</p><p>Methods</p><p>The study was based on a qualitative methodology, comprising 32 semistructured interviews with advanced cancer patients admitted to the palliative care unit of the Medical University of Vienna. Interviews were conducted with 20 patients during the first three days after admission to the unit and after one week, recorded digitally, and transcribed verbatim. Data were analyzed using NVivo 10 software, based on thematic analysis enhanced with grounded theory techniques.</p><p>Results</p><p>The results revealed four themes: (1) information about palliative care, (2) supportive care needs, (3) being treated in a palliative care unit, and (4) qualities required of palliative care physicians. The data showed that patients lack information about palliative care, that help in social concerns plays a central role in palliative care, and attentiveness as well as symptom management are important to patients. Patients desire a personal patient-physician relationship. The qualities of a good palliative care physician were honesty, the ability to listen, taking time, being experienced in their field, speaking the patient’s language, being human, and being gentle. Patients experienced relief when being treated in a palliative care unit, perceived their care as an interdisciplinary activity, and felt that their burdensome symptoms were being attended to with emotional care. Negative perceptions included the overtly intense treatment.</p><p>Conclusions</p><p>The results of the present study offer an insight into what patients expect from palliative care teams. Being aware of patient’s needs will enable medical teams to improve professional and individualized care.</p></div