Daytime symptoms of chronic obstructive pulmonary disease:a systematic review

There is no single source of compiled data on symptoms experienced by patients with chronic obstructive pulmonary disease (COPD) when awake and active throughout the day. The aim of this systematic review was to evaluate the prevalence, variability, and burden (i.e., bothersomeness and/or intensity), and the impact of daytime COPD symptoms on other outcomes. The review also evaluated the impact of interventions and the measures/tools used to assess daytime COPD symptoms in patients. A systematic literature search was conducted using the primary search terms "COPD", "symptoms", and "daytime" in EMBASE®, MEDLINE®, MEDLINE® In-Process, and CENTRAL in 2016, followed by an additional search in 2018 to capture any new literature that was published since the last search. Fifty-six articles were included in the review. The accumulated evidence indicated that the symptomatic burden of COPD appears greatest in the morning, particularly upon waking, and that these morning symptoms have a substantial impact on patients' ability to function normally through the day; they also worsen quality of life. A wide variety of tools were used to evaluate symptoms across the studies. The literature also confirmed the importance of pharmacotherapy in the management of daytime COPD symptoms, and in helping normalize daily functioning. More research is needed to better understand how COPD symptoms impact daily functioning and to evaluate COPD symptoms at well-defined periods throughout the day, using validated and uniform measures/tools. This will help clinicians to better define patients' needs and take appropriate action

Targeting exertional breathlessness to improve physical activity:the role of primary care

Primary care physicians (PCPs) play a crucial role in the diagnosis and management of chronic obstructive pulmonary disease (COPD). By working together with patients to target exertional breathlessness and increase physical activity, PCPs have an important role to play, early in the disease course, in improving patient outcomes in both the short and long term. In this article, we consider how physical activity affects disease progression from the PCP perspective. We discuss the role of pharmacological therapy, the importance of an holistic approach and the role of PCPs in assessing and promoting physical activity. The complexity and heterogeneity of COPD make it a challenging disease to treat. Patients’ avoidance of activity, and subsequent decline in capacity to perform it, further impacts the management of the disease. Improving patient tolerance of physical activity, increasing participation in daily activities and helping patients to remain active are clear goals of COPD management. These may require an holistic approach to management, including pulmonary rehabilitation and psychological programmes in parallel with bronchodilation therapy, in order to address both physiological and behavioural factors. PCPs have an important role to optimise therapy, set goals and communicate the importance of maintaining physical activity to their patients. In addition, optimal treatment that addresses activity-related breathlessness can help prevent the downward spiral of inactivity and get patients moving again, to improve their overall health and long-term prognosis

Use of electronic medical records and biomarkers to manage risk and resource efficiencies

Peer reviewedPublisher PD

Personalized medication adherence management in asthma and COPD:a review of effective interventions and development of a practical adherence toolkit

BACKGROUND: Medication non-adherence management of patients with asthma/COPD remains challenging. Given the multitude of underlying causes, a personalized approach is required. The Test of Adherence to Inhalers (TAI) can identify reasons for non-adherence, but does not provide guidance on how to effectively act on results. OBJECTIVE: To develop a practical, evidence-based decision support toolkit for healthcare professionals managing adult patients with asthma and/or COPD, by matching TAI-identified adherence barriers to proven effective adherence enhancing interventions. METHODS: A literature review in PubMed and Embase was performed identifying interventions that enhanced medication adherence in adult patients with asthma and/or COPD. Randomised controlled trials (RCTs) published in English with full-texts available were included. Effective interventions were assessed by the Cochrane risk of bias tool, categorized, matched with specific TAI responses and developed into a practical TAI Toolkit. The Toolkit was assessed on content and usability (System Usability Scale, SUS) by a multidisciplinary group of healthcare professionals. RESULTS: Forty RCTs were included in the review. In total, seven effective interventions catergories were identified, informing the TAI Toolkit: reminders, educational interventions, motivational strategies, feedback on medication use, shared decision making, simplifying medication regimen and multiple component interventions. Healthcare professionals rated the TAI Toolkit with a mean SUS score of 71.4 (range: 57.5-80.0). CONCLUSION: Adherence can be improved using different interventions that the TAI Toolkit helps selecting. The TAI Toolkit was well received by healthcare professionals. Further research is required to test its validity, practicality and effectiveness in practice

A Charter to Fundamentally Change the Role of Oral Corticosteroids in the Management of Asthma

Asthma affects 339 million people worldwide, with an estimated 5–10% experiencing severe asthma. In emergency settings, oral corticosteroids (OCS) can be lifesaving, but acute and long-term treatment can produce clinically important adverse outcomes and increase the risk of mortality. Therefore, global guidelines recommend limiting the use of OCS. Despite the risks, research indicates that 40–60% of people with severe asthma are receiving or have received long-term OCS treatment. Although often perceived as a low-cost option, long-term OCS use can result in significant health impairments and costs owing to adverse outcomes and increased utilization of healthcare resources. Alternative treatment methods, such as biologics, may produce cost-saving benefits with a better safety profile. A comprehensive and concerted effort is necessary to tackle the continued reliance on OCS. Accordingly, a threshold for OCS use should be established to help identify patients at risk of OCS-related adverse outcomes. Receiving a total dose of more than 500 mg per year should trigger a review and specialist referral. Changes to national and local policies, following examples from other chronic diseases, will be crucial to achieving this goal. Globally, multiple barriers to change still exist, but specific steps have been identified to help clinicians reduce reliance on OCS. Implementing these changes will result in positive health outcomes for patients and social and economic benefits for societies.</p

Improving antibacterial prescribing safety in the management of COPD exacerbations:systematic review of observational and clinical studies on potential drug interactions associated with frequently prescribed antibacterials among COPD patients

BACKGROUND: Guidelines advise the use of antibacterials (ABs) in the management of COPD exacerbations. COPD patients often have multiple comorbidities, such as diabetes mellitus and cardiac diseases, leading to polypharmacy. Consequently, drug-drug interactions (DDIs) may frequently occur, and may cause serious adverse events and treatment failure. OBJECTIVES: (i) To review DDIs related to frequently prescribed ABs among COPD patients from observational and clinical studies. (ii) To improve AB prescribing safety in clinical practice by structuring DDIs according to comorbidities of COPD. METHODS: We conducted a systematic review by searching PubMed and Embase up to 8 February 2018 for clinical trials, cohort and case-control studies reporting DDIs of ABs used for COPD. Study design, subjects, sample size, pharmacological mechanism of DDI and effect of interaction were extracted. We evaluated levels of DDIs and quality of evidence according to established criteria and structured the data by possible comorbidities. RESULTS: In all, 318 articles were eligible for review, describing a wide range of drugs used for comorbidities and their potential DDIs with ABs. DDIs between ABs and co-administered drugs could be subdivided into: (i) co-administered drugs altering the pharmacokinetics of ABs; and (ii) ABs interfering with the pharmacokinetics of co-administered drugs. The DDIs could lead to therapeutic failures or toxicities. CONCLUSIONS: DDIs related to ABs with clinical significance may involve a wide range of indicated drugs to treat comorbidities in COPD. The evidence presented can support (computer-supported) decision-making by health practitioners when prescribing ABs during COPD exacerbations in the case of co-medication

Primary care cohort study in the sequence of diagnosing chronic respiratory diseases and prescribing inhaled corticosteroids

To prevent unnecessary use of inhaled corticosteroids (ICS), ICS treatment should only be started when the diagnostic process of asthma and COPD is completed. Little is known about the chronological order between these diagnoses and the start of ICS. We performed a retrospective cohort study, based on electronic medical records of 178 Dutch general practices, to explore the temporal relations between starting continuous use of ICS and receiving a diagnosis of asthma and/or COPD. The database included information of patients who were registered with a diagnosis of asthma and/or COPD in one of the practices during January 1, 2012 and December 31, 2013. Two or more successive prescriptions of ICS within 6 months were considered as continuous ICS treatment. The chronological order of events based on available dates were analysed using descriptive analyses. For 8507 patients with asthma, 4024 patients with COPD, and 801 patients with asthma-COPD overlap (ACO), the order of events could be analysed. In total, 1857 (14.4%) patients started ICS prior to their diagnosis, 11.5, 20.8, and 10.0% of patients with asthma, COPD, and ACO, respectively. In 53.4% of the patients, the first prescription of ICS was a combination inhaler with a long-acting bronchodilator. In this real-life primary care cohort, one in seven patients started ICS treatment prior to their diagnosis and approximately half of the patients started with a combination inhaler. Our findings suggest that there is relevant room for improvement in the pharmaceutical management of patients with these chronic respiratory diseases