Withdrawal of inhaled corticosteroids in COPD patients: rationale and algorithms

Observational studies indicate that overutilization of inhaled corticosteroids (ICS) is common in patients with chronic obstructive pulmonary disease (COPD). Overprescription and the high risk of seriou

Эффективность комбинаций ингаляционных глюкокортикостероидов и длительно действующих β-агонистов в условиях реальной медицинской практики: результаты многоцентрового кросс-секционного исследования у российских пациентов с бронхиальной астмой

Asthma management approaches are improving yearly, but the problem of asthma control is still acute. Combinations of inhaled glucocorticosteroids (ICS) and long-acting β2-agonists (LABA) play a crucial role in asthma therapy, but their effectiveness in real practice can be insufficient, and asthma control level in the population remains low. Optimizing the use of these drugs, changing the usual therapy regimens, and implementing upgraded inhalers can improve adherence to treatment and inhalation technique, which affects the effectiveness of the therapy.The study aimed to describe the key characteristics of the patient population getting asthma treatment in real clinical practice and assess factors influencing asthma control, including adherence to therapy.Methods. A single-stage cross-sectional observational study in 124 primary health care centers in 22 cities of the Russian Federation included 3,214 patients > 18 years old, with a clinical diagnosis of asthma for at least 1 year, who were able to perform a spirometry test and fill out the ACQ-5 and TAI-12 questionnaires.Results. Assessment of asthma control with the ACQ-5 questionnaire showed that most patients had uncontrolled asthma (56%). Controlled and partially controlled asthma was diagnosed in 21 and 19% of patients, respectively. 4% of patients had severe uncontrolled asthma. The TAI questionnaire revealed low adherence to therapy in more than half of the patients (53.6%). The rate of patients with controlled asthma and the average annual frequency of exacerbations were significantly lower in subgroups of patients who received therapy with extrafine ICS/LABA and ICS/formoterol in single inhaler regimen, compared with controller therapy using fixed and free combinations of ICS and LABA.Conclusion. The main causes of insufficient asthma control are low adherence to treatment, inhalation errors, monotherapy with ICS, asthma with small airways dysfunction, and adverse events associated with ICS. Prescribing the combinations of ICS/LABA in the form of extra-fine aerosol and using it in the Maintenance and Reliever Therapy (MART) regimen can significantly increase asthma control, reduce the risk of adverse events, and increase patient adherence to treatment. A potential alternative to improve asthma control is administering ICS-LABA combinations once daily. Подходы к терапии бронхиальной астмы (БА) совершенствуются с каждым годом, однако проблема контроля над ней по-прежнему остается актуальной. Ключевую роль в терапии БА играют комбинации ингаляционных глюкокортикостероидов (иГКС) и длительно действующих β2-агонистов (ДДБА), однако в реальной практике такая терапия зачастую оказывается недостаточно эффективной и уровень контроля над БА в популяции остается низким. При оптимизации использования этих препаратов, изменении привычных режимов терапии и внедрении в практику усовершенствованных ингаляторов могут улучшиться приверженность терапии и техника ингаляции, что, в свою очередь, влияет на эффективность терапии.Целью исследования явилось описание ключевых характеристик выборки пациентов, получающих терапию БА в условиях реальной практики, и оценка факторов, влияющих на достижение ими контроля над БА, в т. ч. на приверженность терапии.Материалы и методы. В одномоментное кросс-секционное наблюдательное исследование, проведенное в 124 центрах оказания первичной медицинской помощи 22 городов Российской Федерации, были включены пациенты (n = 3 214) старше 18 лет с клиническим диагнозом БА, установленным ≥ 1 года назад, которые были способны выполнить спирометрический тест и заполнить опросники по приверженности ингаляторам (Test of the Adherence to Inhalers – TAI-12) и контролю над БА (Asthma Control Questionnaire – ACQ-5).Результаты. По результатам оценки контроля над БА по ACQ-5 показано, что среди участников исследования преобладали больные с неконтролируемой БА – 56 %. Контролируемая и частично контролируемая БА диагностирована у 21 и 19 % соответственно. Еще у 4 % больных отмечалась тяжелая неконтролируемая БА. У 53,6 % больных при оценке по TAI-12 выявлен низкий уровень приверженности терапии. Доля пациентов с контролируемой БА и средняя частота обострений в год были достоверно ниже в подгруппах пациентов, получавших терапию комбинацией иГКС / ДДБА в виде экстрамелкодисперсного аэрозоля (ЭМДА) и комбинацией иГКС / формотерол в режиме единого ингалятора, по сравнению с базисной терапией фиксированными и свободными комбинациями иГКС и ДДБА.Заключение. Основными препятствиями для достижения контроля над БА являются низкая приверженность терапии, монотерапия иГКС, ошибки при выполнении ингаляций, БА с поражением малых дыхательных путей и нежелательные эффекты терапии иГКС. При назначении комбинации иГКС / ДДБА в виде ЭМДА в режиме единого ингалятора для базисной терапии и купирования симптомов (Maintenance and Reliever Therapy – MART) значимо увеличивается контроль над БА, снижается риск нежелательных явлений и повышается приверженность пациентов лечению. Возможной альтернативой для улучшения контроля над БА является назначение комбинаций иГКС / ДДБА для приема 1 раз в день

Russian guidelines for the management of COPD: algorithm of pharmacologic treatment

The high prevalence of COPD together with its high level of misdiagnosis and late diagnosis dictate the necessity for the development and implementation of clinical practice guidelines (CPGs) in order to improve the management of this disease. High-quality, evidencebased international CPGs need to be adapted to the particular situation of each country or region. A new version of the Russian Respiratory Society guidelines released at the end of 2016 was based on the proposal by Global Initiative for Obstructive Lung Disease but adapted to the characteristics of the Russian health system and included an algorithm of pharmacologic treatment of COPD. The proposed algorithm had to comply with the requirements of the Russian Ministry of Health to be included into the unified electronic rubricator, which required a balance between the level of information and the simplicity of the graphic design. This was achieved by: exclusion of the initial diagnostic process, grouping together the common pharmacologic and nonpharmacologic measures for all patients, and the decision not to use the letters A–D for simplicity and clarity. At all stages of the treatment algorithm, efficacy and safety have to be carefully assessed. Escalation and de-escalation is possible in the case of lack of or insufficient efficacy or safety issues. Bronchodilators should not be discontinued except in the case of significant side effects. At the same time, inhaled corticosteroid (ICS) withdrawal is not represented in the algorithm, because it was agreed that there is insufficient evidence to establish clear criteria for ICSs discontinuation. Finally, based on the Global Initiative for Obstructive Lung Disease statement, the proposed algorithm reflects and summarizes different approaches to the pharmacological treatment of COPD taking into account the reality of health care in the Russian Federation

Continuing to Confront COPD International Physician Survey: Physician Knowledge and Application of COPD Management Guidelines in 12 Countries

AIM: Utilizing data from the Continuing to Confront COPD (chronic obstructive pulmonary disease) International Physician Survey, this study aimed to describe physicians\u27 knowledge and application of the GOLD (Global initiative for chronic Obstructive Lung Disease) Global Strategy for the Diagnosis, Management and Prevention of COPD diagnosis and treatment recommendations and compare performance between primary care physicians (PCPs) and respiratory specialists. MATERIALS AND METHODS: Physicians from 12 countries were sampled from in-country professional databases; 1,307 physicians (PCP to respiratory specialist ratio three to one) who regularly consult with COPD, emphysema, or chronic bronchitis patients were interviewed online, by telephone or face to face. Physicians were questioned about COPD risk factors, prognosis, diagnosis, and treatment, including knowledge and application of the GOLD global strategy using patient scenarios. RESULTS:Physicians reported using spirometry routinely (PCPs 82%, respiratory specialists 100%; P\u3c0.001) to diagnose COPD and frequently included validated patient-reported outcome measures (PCPs 67%, respiratory specialists 81%; P\u3c0.001). Respiratory specialists were more likely than PCPs to report awareness of the GOLD global strategy (93% versus 58%, P\u3c0.001); however, when presented with patient scenarios, they did not always perform better than PCPs with regard to recommending GOLD-concordant treatment options. The proportion of PCPs and respiratory specialists providing first- or second-choice treatment options concordant with GOLD strategy for a GOLD B-type patient was 38% versus 67%, respectively. For GOLD C and D-type patients, the concordant proportions for PCPs and respiratory specialists were 40% versus 38%, and 57% versus 58%, respectively. CONCLUSION: This survey of physicians in 12 countries practicing in the primary care and respiratory specialty settings showed high awareness of COPD-management guidelines. Frequent use of guideline-recommended COPD diagnostic practices was reported; however, gaps in the application of COPD-treatment recommendations were observed, warranting further evaluation to understand potential barriers to adopt guideline recommendations

Health Behaviors and Their Correlates Among Participants in the Continuing to Confront COPD International Patient Survey

Background and aims: We used data from the Continuing to Confront COPD International Patient Survey to test the hypothesis that patients with COPD who report less engagement with their disease management are also more likely to report greater impact of the disease. Methods: This was a population-based, cross-sectional survey of 4,343 subjects aged ≥ 40 years from 12 countries, fulfilling a case definition of COPD based on self-reported physician diagnosis or symptomatology. The impact of COPD was measured with COPD Assessment Test, modified Medical Research Council Dyspnea Scale, and hospital admissions and emergency department visits for COPD in the prior year. The 13-item Patient Activation Measure (PAM-13) instrument and the 8-item Morisky Medication Adherence Scale (MMAS-8) were used to measure patient disease engagement and medication adherence, respectively. Results: Twenty-eight percent of subjects reported being either disengaged or struggling with their disease (low engagement: PAM-13 levels 1 and 2), and 35% reported poor adherence (MMAS-8 \u3c 6). In univariate analyses, lower PAM-13 and MMAS-8 scores were significantly associated with poorer COPD-specific health status, greater breathlessness and lower BMI (PAM-13 only), less satisfaction with their doctor’s management of COPD, and more emergency department visits. In multivariate regression models, poor satisfaction with their doctor’s management of COPD was significantly associated with both low PAM-13 and MMAS-8 scores; low PAM-13 scores were additionally independently associated with higher COPD Assessment Test and modified Medical Research Council scores and low BMI (underweight). Conclusion: Poor patient engagement and medication adherence are frequent and associated with worse COPD-specific health status, higher health care utilization, and lower satisfaction with health care providers. More research will be needed to better understand what factors can be modified to improve medication adherence and patient engagement

Современные данные о возможностях улучшения переносимости физической нагрузки и значении физической активности у больных с хронической обструктивной болезнью легких

Physical activity plays an important prognostic role in patients with chronic obstructive pulmonary disease (COPD). According to published data, decreased physical activity is associated with higher frequency of COPD exacerbations, higher mortality, and lower quality of life in COPD patients. As the airflow limitation is an underlying mechanism of COPD, double bronchodilators can reduce lung hyperinflation and improve exercise tolerance in patients with COPD. According to the robust evidence on the efficacy of tiotropium/olodaterol combination, double bronchodilators can increase exercise duration and time before dyspnea occurrence on exertion. However, further studies are needed in the field of rehabilitation and a role of physical activity in the management of patients with COPD.При определении тяжести течения и прогноза у пациентов с хронической обструктивной болезнью легких (ХОБЛ) важная роль принадлежит такому фактору, как физическая активность (ФА). По данным современных исследований продемонстрировано, что снижение ФА ассоциировано с увеличением частоты обострений ХОБЛ, летальности и снижением качества жизни больных ХОБЛ. Поскольку основу заболевания составляет ограничение воздушного потока, то при уменьшении легочной гиперинфляции при помощи двойных бронходилататоров переносимость физической нагрузки (ФН) у пациентов с ХОБЛ может улучшиться. Согласно существующим данным о применении комбинации тиотропий / олодатерол убедительно доказано, что при использовании двойных бронходилататоров у больных ХОБЛ увеличиваются время переносимости ФН и период до появления одышки во время ФН. Вместе с тем требуются дальнейшие исследования в области реабилитации и использования ФН в терапии пациентов с ХОБЛ

The position of the fixed combination of indacaterol, glycopyrronium, and mometasone furoate in the management of bronchial asthma. The Report of Expert Panel of Russian Respiratory Society

Achieving the control of bronchial asthma (BA) in real clinical practice remains an unresolved problem, despite the expansion of therapeutic options in this area. Guidelines about when and for whom should a particular treatment be used continue to develop. Increasing of inhaled corticosteroid dose (ICS) in combination with a long-acting β2-agonist (LABA) does not always lead to the desired result, although a combined LABA-ICS inhaler could improve the course of asthma and increase adherence. The addition of tiotropium bromide to LABA-ICS requires the use of two inhalers. The targeted biological therapy is associated with the complexity of phenotyping and is possible only in specialized medical centers. Mometasone furoate, indacaterol acetate, and glycopyrronium bromide in fixed doses were combined in Breezhaler® inhaler for asthma maintenance therapy once per day. This way of treatment helps to realize full potential of maintenance inhalation therapy of bronchial asthma and to simplify the achievement of control over the disease in routine clinical practice.Достижение контроля над бронхиальной астмой (БА) в реальной клинической практике остается нерешенной проблемой, несмотря на существенное расширение терапевтических возможностей в этом направлении. Рекомендации о том, когда и для кого должны использоваться те или иные методы лечения, продолжают расширяться. При увеличении дозы ингаляционного глюкокортикостероида (иГКС) в комбинации с длительно действующим β2-агонистом (ДДБА) далеко не всегда достигается желаемый результат, хотя при использовании единого ингалятора иГКС / ДДБА может улучшиться течение БА и повыситься приверженность терапии. При добавлении тиотропия бромида к иГКС / ДДБА требуется использование 2 ингаляторов, а назначение таргетной биологической терапии связано со сложностью фенотипирования и возможно только в специализированных медицинских центрах. Мометазона фуроат, индакатерола ацетат и гликопиррония бромид объединены в фиксированную комбинацию, доставляемую с помощью ингалятора Бризхалер® 1 раз в день для поддерживающей терапии БА. Этот способ лечения помогает реализовать потенциал базисной ингаляционной терапии БА и упростить достижение контроля над заболеванием в повседневной клинической практик

Exterior and constitutional features of first-calf cows of black-and-white cattle of different genotypes

The dairy cattle breeding development depends largely on the culture of raising young animals of the cattle. Production and maintaining healthy young animals is an extremely challenging task for livestock breeders [1,3,12,14]. Breeding of dairy replacement heifers is considered a major element of the breeding system and milk production technology, since the formation of milk production takes place just in the process of growth and development. Individual selection of parental pairs affects not only the cattle reproductive ability, but also the growth of offspring [2, 4,13], [5-11]

Frequency distribution of polymorphic variants of the beta-casein locus in Russian various breed cattle subpopulations

Using the author’s test system, 2607 Holstein, Ayrshire and Jersey breeds were genotyped at CSN2 locus. It was determined that the frequency of preferred genotype A2A2 is in Holstein, Ayrshire and Jersey groups of animals - 0.21; 0.25 and 0.60 respectively. The frequency of A2 allele in Holstein breed is 0.48; in Ayrshire - 0.51; in Jersey - 0.78. Thus, the Russian subpopulations of Ayrshire, Jersey, and Holstein cattle subpopulations according to frequencies of A2A2 genotypes (CSN2 locus), the Jersey breed has the best indicators (0.60). Russian breeding enterprises selling semen production of Ayrshire and Holstein bulls should increase the share of breeders with CSN2 genotypes A2A2

Recommendations for COPD management in Central and Eastern Europe

Introduction: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for patients with COPD can vary widely, even in geographically close and economically similar countries. ----- Areas covered: Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking recommendations from the GOLD 2022 report into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE. ----- Expert opinion: Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate