COPD World News - 2019
Toronto, ON – An interview recently published by the Canadian Medical Association highlighted the gap between diagnosis and treatment in Canada. As a family doctor at St. Michael’s Hospital in Toronto, Dr. Persaud details a typical scenario he sees in his practice. A patient with poorly controlled diabetes or high blood pressure comes in and he prescribes them medication, but the patient doesn’t take it because they can’t afford it. At some point, the same patient returns with the same problem. In his early years of practice, Dr. Persaud believed there was nothing he could do to fix this cycle. But once some of these same patients started having heart attacks and strokes, he felt compelled to act. “It’s unacceptable that people are being harmed unnecessarily, when there are relatively inexpensive treatments that could prevent it,” Dr. Persaud explains. “There are millions of people across Canada who can’t afford medications, so let’s do something that might inform public policy and improve the situation for everyone.” So in 2016, Dr. Persaud launched the CLEAN Meds (Carefully selected and easily accessible at no charge medications) study, a randomized controlled trial testing the effects of providing patients access to more than 125 “essential medicines” for free. Almost 800 people are now taking part in the study through seven health centres: four in Toronto and three in the Manitoulin Island area. At the time they were enrolled, all the patients had reported being unable to afford a medication during the previous 12 months. “The current system - a mishmash of private insurance, public insurance and no insurance - is a mess that leaves taxi drivers, factory workers, entrepreneurs, musicians and others in a position where often, they can’t afford to take medications, and have to make very difficult decisions.” Half of the participants were randomly placed in the control group, without any additional support for filling their prescription. The other half were assigned to the intervention group and had a pharmacist in the study mail their medications — for free — directly to their homes. A patient with diabetes, for instance, would receive metformin and insulin at no charge. “By comparing the two groups, we can determine the effects of free and convenient access to medications,” says Dr. Persaud. “Do people take the medications as instructed, are the medications more likely to be prescribed appropriately, and do people have better control of their conditions and diseases?” The list of essential medicines created for the study is adapted from a similar list published by the World Health Organization and tailored to the Canadian market. It ranges from inexpensive medications such as acetaminophen and vitamin D to what Dr. Persaud calls “fantastically expensive” biologics such as dolutegravir, a new HIV treatment that costs roughly $10,000 a year. He says several drugs that are commonly prescribed were kept off the list because there was no evidence, they are effective. Results from the first 12 months of the CLEAN Meds study are expected to be published in early 2019, shortly before the Advisory Council on the Implementation of National Pharmacare issues its final report. The council, chaired by Dr. Eric Hoskins, is leading a national dialogue on how to implement affordable national pharmacare for Canadians and their families, employers and governments.
For more information: https://www.cma.ca/dr-nav-persaud
Lung transplant patients told to fund-raise to pay for
life saving treatment
Halifax, NS - CBC Radio reported that some patients in
Atlantic Canada can't afford cost of lung transplants, and are choosing to die
instead. Atlantic Canadian patients who need lung transplants must move to
Toronto for the life-saving surgery, but because the high cost of the move is
not fully financially supported, some are simply choosing to die. "I
have now had three patients, from Nova Scotia, who have decided not to
go," said Dr. Meredith Chiasson, a respirologist based in Halifax. Those
patients have not died yet, but "are coming to the end of their
lives," she told The Current's guest host Piya Chattopadhyay. Lung
transplants are covered by the health-care system, but as the operation is not
available in Atlantic Canada, patients must relocate to Toronto for potentially
six to 12 months. Each province has its own allowances to help with the cost:
patients from P.E.I. get $1,000 a month; there's $1,500 a month available in
Nova Scotia and New Brunswick; and $3,000 a month for those from Newfoundland
and Labrador. They face financial ruin to get a new lung. Some are choosing to
die instead That financial aid can fall short of Toronto's high cost of living
however, leaving patients scrambling to make up the difference. Natalie
Jarvis, a patient who spoke to CBC News, tried to find accommodation
in Toronto and was quoted rental rates as high as $5,000 a month. Chiasson said
that in order to get her patients to Ontario for treatment, she has to tell
them to fundraise. "I hate having to tell them that right now, when you
can barely speak a full sentence, I need you to go out and pound the pavement
to try and earn money so you can live," she told Chattopadhyay. You
are going to have to do fundraising or something else to come up with this
money, because right now it's not coming from our government,” said Dr.
Meredith Chiasson. "I tell them that's the reality of the situation we're
in right now: you are going to have to do fundraising or something else to come
up with this money, because right now it's not coming from our
government." She said that conversations around health become secondary at
that point, as money becomes the focus. "I have a hard time getting them
to listen to some of the other things I need them to hear," she said.
"We need to talk about the drugs they have to take, and the side-effects,
and survival after a lung transplant. "There's a big conversation we need
to have about transplants, but all they focus on is the money."
For more information: https://tinyurl.com/y2o6e3n9
Salzburg, Austria There are several reports on underdiagnosis of COPD, while little is known about COPD overdiagnosis and overtreatment. Researchers here describe the overdiagnosis and the prevalence of spirometrically defined false positive COPD, as well as their relationship with overtreatment across 23 population samples in 20 countries participating in the BOLD Study between 2003 and 2012. A false positive diagnosis of COPD was considered when participants reported a doctor’s diagnosis of COPD, but postbronchodilator spirometry was unobstructed (FEV1/FVC > LLN). Additional analyses were performed using the fixed ratio criterion (FEV1/FVC < 0.7). Among 16,177 participants, 919 (5.7%) reported a previous medical diagnosis of COPD. Postbronchodilator spirometry was unobstructed in 569 subjects (61.9%): false positive COPD. A similar rate of overdiagnosis was seen when using the fixed ratio criterion (55.3%). In a subgroup analysis excluding participants who reported a diagnosis of “chronic bronchitis” or “emphysema” (n = 220), 37.7% had no airflow limitation. The site-specific prevalence of false positive COPD varied greatly, from 1.9% in low- to middle-income countries to 4.9% in high-income countries. In multivariate analysis, overdiagnosis was more common among women, and was associated with higher education; former and current smoking; the presence of wheeze, cough, and phlegm; and concomitant medical diagnosis of asthma or heart disease. Among the subjects with false positive COPD, 45.7% reported current use of respiratory medication. Excluding patients with reported asthma, 34.4% of those with normal spirometry still used a respiratory medication. The researchers concluded that false positive COPD is frequent. This might expose non-obstructed subjects to possible adverse effects of respiratory medication. The study was published in the journal CHEST.
For more information: https://journal.chestnet.org/article/S0012-3692(19)30066-2/fulltext
The risks of e-cigarette use in COPD might be greater than in people without COPD
Sydney, Australia – A study recently published in the European Respiratory Journal looked at e-cigarettes that are often used as an alternative to cigarette smoking and as nicotine replacement therapy. Some suggestions are that they are markedly less harmful than cigarettes to the user. The confusion around the safety of e-cigarettes stems from contradictory findings in which variations in experimental methodology and the testing of different devices has not been accounted for. The harms associated with their use are not well understood and this is commonly misconceived as meaning that they are a healthy alternative to smoking. This misconception is further exacerbated by physicians and public health bodies which have made recommendations without strong scientific evidence. Multiple studies have concluded that e-cigarette vapour exposure could lead to inflammation, emphysema and a greater risk of bacterial and viral infection. The lack of a defined model for e-cigarette exposure for both in vitro cellular and in vivo animal studies has led to contradictory findings between studies. Such differences can be attributed to different devices (first versus fourth generation), vaporisation temperature, different E-liquids or the concentration of e-cigarette vapour used. The confusion caused by contradictory findings leaves consumers and clinicians to form their own opinions about e-cigarettes safety which may lead to further public health issues in the future. Furthermore, no studies have compared responses in cells from people with chronic obstructive pulmonary disease (COPD), a disease state where the use of e-cigarettes is particularly attractive. However, COPD lung cells are known to be hyperresponsive to a range of environmental stimuli including cigarette smoke and pollution, and therefore might also respond differently to e-cigarette vapour. The aim of this study was to evaluate dose–response relationships of e-cigarette stimulation of primary airway smooth muscle cells (ASMCs) from people with and without COPD under realistic physiological conditions. ASMCs were chosen for this study because of their contribution to pathological processes in COPD. Not only is smooth muscle bulk increased in COPD airways, ASMCs have been shown to secrete increased inflammatory mediators and chemokines compared with cells from smokers without COPD, suggesting their response to inflammatory stimuli might contribute to lung inflammation and/or disease progression in COPD. We have previously shown that ASMCs and airway fibroblasts from people with COPD are hyperresponsive to cigarette smoke, and hypothesised that they would also be hyperresponsive to e-cigarettes. We also hypothesised that the increased toxic by-product formation seen at higher vaporisation temperatures would result in greater cytotoxicity in ASMCS. Patients with COPD, or smokers, might switch to e-cigarettes as an alternative nicotine source, believing that they are safer. All e-cigarette aerosols increased CXCL8 production in ASMCs irrespective of flavour or nicotine concentration. This suggests that e-cigarettes would stimulate lung neutrophilic inflammation. Furthermore, our data suggests that e-cigarette aerosol stimulates COPD cells in a similar manner to cigarette smoke, resulting in an increased production of CXCL8 from COPD cells compared with non-COPD cells. Overall, our data suggests that COPD patients should avoid using e-cigarettes as a smoking cessation aid as they have a similar ability to stimulate inflammation and lung damage as cigarette smoke, and thus potentially accelerate their disease progression.
For more information: https://tinyurl.com/yxlfnvsb
Triple therapy (ICS/LABA/LAMA) in COPD: thinking out of the box
London, UK - Triple inhaler therapy in COPD might in some real-life situations be useful outside of the strict indications reported by the registration agencies, but at the same time in some other situations it could be better avoided, even when recommended. A current hot topic in COPD is that two “fixed triple” combinations of an inhaled corticosteroid (ICS), a long-acting β]. For the time being, the additional benefit of a fixed triple LABA/LAMA/ICS combination is related to convenience for the patient, and possibly improved compliance. However, the researchers here speculated that the simultaneous delivery to the target organ of three agents with different mechanisms of action may improve positive interactions between them. In addition, triple therapy might improve activity levels through bronchodilation or reduced breathlessness, and thereby improve respiratory muscle strength and impact upon disease progression.-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) in a single inhaler have become available for patients with COPD, and a third triple therapy is in advanced development with the first large randomised clinical trial (RCT) recently published in Lancet Respiratory Medicine Vol 5 Issue 1.Whether triple therapy in a single inhaler outperforms the three individual components given in separate inhalers is unknown. In fact, there is only one study where the triple therapy in a single inhaler was compared to triple therapy in separate inhalers, but the LAMA was different with glycopyrronium in the former (BDP/FF/G) and tiotropium in the latter. The two triple therapies were equally effective, and both superior to tiotropium alone [There is only one triple therapy currently available in Canada as a single inhaler. The brand name if Trelegy Ellipta - fluticasone-furoate/vilanterol/umeclidinium
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For more information: https://tinyurl.com/y5uoxc5l
London, UK - If you thought ditching regular smokes for an e-cig or heated tobacco device was a way to save your lungs, you’d be wrong. That’s the message coming from a team of Australian researchers who say that any kind of smoking is ‘toxic’. It’s at odds with plenty of campaigners who say that vaping and heated tobacco devices are safer than traditional cigarettes. But the scientists took a look at a ‘next generation’ heated tobacco device on sale globally and found it still damaged human lungs by changing their structure and creating an inflammatory response. Dr Sukhwinder Sohal led the study from the University of Tasmania, which looked at cigarettes, e-cigarettes and the heated tobacco IQOS device made by tobacco giant Philip Morris International. ‘Our results suggest that all three are toxic to the cells of our lungs and that these new heated tobacco devices are as harmful as smoking traditional cigarettes. ‘Damage to these two types of lung cells can destroy lung tissue leading to fatal diseases such as chronic obstructive pulmonary disease, lung cancer and pneumonia, and can increase the risk of developing asthma, including in unborn children. ‘So we should not assume that these devices are a safer option.’ While e-cigarettes and heated tobacco still contain nicotine (the addictive substance in ciggies) but it’s in liquid form and is heated into vapour. Which limits some of the damage caused by standard cigarette smoke and ash. As part of the study, the team did lab tests on the effects of all three devices on epithelial cells (which line your organs) and smooth muscle cells taken from the human airways. Cigarette smoke and heated tobacco were highly toxic while vaping induced a ‘cry for help’ inflammatory response. Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, who was not involved in the research, said the study suggested a need for ‘considerable caution’ on heat-not-burn products, although their impact is not fully understood. E-cigarettes produce vaporized nicotine (PA) He said: ‘E-cigarettes are often presented as safer than cigarettes because they also deliver nicotine but contain no tar, the cause of lung cancer. ‘But they contain many things not found in conventional cigarettes. ‘We really have very little idea about the specific risks associated with e-cigarettes but the evidence that is emerging indicates that they are far from safe, with risks to the heart and lungs. This study adds to that body of evidence.’ Public Health England has urged smokers to use e-cigarettes, calling concerns over vaping ‘false fears’. But the study, published in the journal ERJ Open Research, says both e-cigarettes and heated tobacco devices causes the same type of damage to cells seen in people with chronic obstructive pulmonary disease (COPD), asthma, bronchitis and emphysema who struggle to breathe. Smoking tobacco will destroy your epithelial cells (Getty Images) Professor Charlotta Pisinger is Chair of the European Respiratory Society’s Tobacco Control Committee and was not involved in the research. She said: ‘These new heated tobacco devices are marketed as producing 95% lower levels of toxic compounds because the tobacco is heated, not burned. However, the first independent studies have shown that combustion is taking place and toxic and carcinogenic compounds are released, some in lower levels than in conventional cigarette smoke, others in higher levels. ‘A review of the tobacco industry’s own data on these devices has shown that, in rats, there is evidence of lung inflammation, and there is no evidence of improvement in lung inflammation and function in smokers who switch to heated tobacco.’ ‘The introduction and vigorous marketing of new devices is very tempting to smokers who want to stop smoking and mistakenly believe they can switch to another harmless tobacco product. ‘It is also opening another avenue for attracting young people to use and become addicted to nicotine. This study adds to evidence that these new devices are not the safe substitute to cigarette smoking they are promoted to be.
For more information: https://tinyurl.com/y2bfnpqr
Effectiveness of long-term use of statins in COPDLanzhou, Gansu, People’s Republic of China - Researchers here performed a general meta-analysis to assess the efficacy of long-term treatment of statins for chronic obstructive pulmonary disease (COPD), and to answer which one is better. For the effect of mortality, inflammatory factors, and lung function index in COPD patients, pooled estimates were produced. They identified the eligible studies from PubMed, Web of Science, Embase, and China National Knowledge Infrastructure, and performed a network meta-analysis to synthetically compare the effectiveness of using different statins in COPD patients. Reduced risks of all-cause mortality, heart disease-related mortality, and COPD acute exacerbation were found in association with statin use in COPD patients in general meta-analysis. In network meta-analysis, the higher cumulative probability in reducing C-reactive protein (CRP) in COPD patients was shown by fluvastatin (97.7%), atorvastatin (68.0%), and rosuvastatin (49.3%) vs other statins. Fluvastatin and atorvastatin more effectively attenuated CRP and pulmonary hypertension (PH) in COPD patients. Overall, statins can attenuate the risk of mortality, the level of CRP, and PH in COPD patients.
For more information: https://tinyurl.com/y2z2og3w
London, UK - Cigarette smokers who attempted to stop smoking with electronic cigarettes and behavioral support were almost twice as likely to be abstinent a year later than those using nicotine-replacement therapies (NRT), a randomized trial showed. British researchers randomly assigned adults attending U.K. National Health Service stop-smoking services to receive either NRT products of their choice, including combinations of products, provided for up to 3 months, or an e-cigarette starter pack (e-liquid strength, 18 mg/mL) with instructions to purchase further e-liquids in the flavors and nicotine strength of their choice. Both groups were also offered weekly behavioral support, reported Dunja Przulj, PhD, of Queen Mary University in London, and colleagues. A year later, the sustained abstinence rate was almost twice as high among the smokers randomized to the e-cigarette group: 18.0% versus 9.9% (relative risk 1.83, 95% CI 130-2.58, <0.001), they wrote in the New England Journal of Medicine. Przulj said the study findings confirm that e-cigarettes are an effective way for smokers to quit smoking. But in an accompanying editorial, Belinda Borrelli, PhD, and George T. O'Connor, MD, both of Boston University, noted that while just 9% of study participants in the NRT arm who were not smoking 1 year after randomization were still using nicotine replacement, 80% of those who stopped smoking using e-cigarettes were still vaping 1 year later. "This differential pattern of long-term use raises concerns about the health consequences of long-term e-cigarette use," they wrote, adding that e-cigarette vapor has been shown to contain toxins that have the potential to negatively impact human cells. They further noted that early studies in mice and humans suggested that these biologic effects impact lung function, although to a lesser extent than cigarette smoking. And, the editorialists worried about second-hand effects on children of those who continue vaping. Not only could those include direct health impacts, but children could also pick up the habit themselves from viewing parents as role models. "These findings argue against complacency in accepting the transition from tobacco smoking to indefinite e-cigarette use as a completely successful smoking-cessation outcome," Borrelli and O'Connor wrote. The randomized trial originally included 886 participants recruited at three NHS smoking cessation service sites from May of 2015 to February of 2018. Adult smokers were invited to participate if they were not pregnant or breast-feeding, had no strong preference to use or not use NRT or e-cigarettes, and were not using either type of product at recruitment. Those randomized to the e-cigarette arm of the trial received a second-generation refillable e-cigarette with one 30 ml bottle of nicotine e-liquid. They were encouraged to purchase future e-liquids online or from local vape shops, and to experiment with different nicotine strengths and flavors if the provided e-liquid did not meet their needs. Participants in the NRT group were informed about the range of products available (gum, patch, lozenge, nasal spray, inhalator, mouth spray, mouth strip, and microtabs) and they selected their preferred product. Combination use -- typically a patch and fast-acting oral NRT -- was encouraged. Participants could also switch products during the trial. The behavioral therapy was offered to both treatment groups as weekly one-on-one sessions delivered for at least 4 weeks after the quit date. Participants were contacted by telephone at weeks 26 and 52, and interviewers asked about product use and smoking abstinence. Respondents who reported abstinence or a reduction in smoking of at least 50% at 52 weeks were invited back to provide carbon monoxide readings to confirm smoking status. Overall, adherence was similar in the two groups, but e-cigarettes were used more frequently and for longer than nicotine replacement over 52 weeks (63 of 79 e-cigarette users who quit smoking were still vaping at 1-year vs four of 44 NRT users who quit smoking cigarettes). "Both e-cigarettes and nicotine-replacement were perceived to be less satisfying than cigarettes," the researchers wrote. "However, e-cigarettes provided greater satisfaction and were rated as more helpful to refrain from smoking than nicotine-replacement products
For more information: https://tinyurl.com/ybvhhcav