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Benefits of high dose N-acetylcysteine to exacerbation-prone COPD patients.

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Benefits of high dose N-acetylcysteine to exacerbation-prone COPD patients.

Chest. 2014 May 15;

Authors: Tse HN, Raiteri L, Wong KY, Ng LY, Yee KS, Tseng CZ

Abstract
ABSTRACT BACKGROUND: Although high-dose NAC has been suggested to reduce COPD exacerbations, it is unclear which category of COPD patients would benefit most from the NAC treatment.
OBJECTIVE: To compare the effect of high-dose NAC (600 mg twice daily) between 'high-risk' and 'low-risk' Chinese COPD patients METHODOLOGY: Spirometry-confirmed stable COPD patients were randomized to treatment with either NAC 600 mg twice daily or placebo, on top of their usual treatments. Patients were followed up at every 16 weeks for a total of 1 year. Further analysis was performed according to patient's exacerbation risk at baseline as defined by the current GOLD strategy for classification of exacerbation risk (high-risk vs. low-risk group) so as to analyze the effect of high-dose NAC in high-risk and low-risk patients.
RESULTS: Of 120 COPD patients randomized (93.2% male, mean age of 70.8 ± 0.74 and pre-bronchodilator %FEV1 53.9 ± 2.0%, baseline characteristics were comparable between the treatment groups), 108 patients (NAC n=52; placebo n=56) completed the 1-year study. For high-risk patients (n=89), high-dose NAC significantly reduced exacerbation frequency (0.85 vs. 1.59, p=0.019*; 1.08 vs. 2.22, p=0.04* at 8 and 12 months, respectively), prolonged time-to-first exacerbation (p=0.02*) and increased the probability of being exacerbation-free at 1 year (51.3% vs. 24.4%, p=0.013*) compared with placebo. This beneficial effect of high-dose NAC versus placebo was not significant in low-risk patients.
CONCLUSION: High-dose NAC (600 mg twice daily for 1 year) reduces exacerbations, and prolongs time to first exacerbation in high-risk but not in low-exacerbation risk Chinese COPD patients.(ClinialTrial.gov ID: NCT01136239).

PMID: 24833327 [PubMed - as supplied by publisher]

Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease.

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Chronic obstructive pulmonary disease (COPD) is a chronic and progressive disease that affects an estimated 10% of the world's population over the age of 40 years. Worldwide, COPD ranks in the top ten for causes of disability and death. Given the significant impact of this disease, it is important to note that acute exacerbations of COPD (AECOPD) are by far the most costly and devastating aspect of disease management. Systemic steroids have long been a standard for the treatment of AECOPD; however, the optimal strategy for dosing and administration of these medications continues to be debated.

OBJECTIVE: To review the use of corticosteroids in the treatment of acute exacerbations of COPD.

MATERIALS AND METHODS: Literature was identified through PubMed Medline (1950-February 2014) and Embase (1950-February 2014) utilizing the search terms corticosteroids, COPD, chronic bronchitis, emphysema, and exacerbation. All reference citations from identified publications were reviewed for possible inclusion. All identified randomized, placebo-controlled trials, meta-analyses, and systematic reviews evaluating the efficacy of systemic corticosteroids in the treatment of AECOPD were reviewed and summarized.

RESULTS: The administration of corticosteroids in the treatment of AECOPD was assessed. In comparison to placebo, systemic corticosteroids improve airflow, decrease the rate of treatment failure and risk of relapse, and may improve symptoms and decrease the length of hospital stay. Therefore, corticosteroids are recommended by all major guidelines in the treatment of AECOPD. Existing literature suggests that low-dose oral corticosteroids are as efficacious as high-dose, intravenous corticosteroid regimens, while minimizing adverse effects. Recent data suggest that shorter durations of corticosteroid therapy are as efficacious as the traditional treatment durations currently recommended by guidelines.

CONCLUSION: Systemic corticosteroids are efficacious in the treatment of AECOPD and considered a standard of care for patients experiencing an AECOPD. Therefore, systemic corticosteroids should be administered to all patients experiencing AECOPD severe enough to seek emergent medical care. The lowest effective dose and shortest duration of therapy should be considered.

Long-acting bronchodilator use after hospitalization for COPD: an observational study of health insurance claims data.

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Treatment of stable chronic obstructive pulmonary disease (COPD) with long-acting bronchodilator (LABD) medications is recommended by the 2014 Global initiative for chronic Obstructive Lung Disease (GOLD) guidelines. The primary objective of this study was to examine LABD prescription fills after a COPD-related hospitalization.

METHODS: This retrospective observational study used claims from Truven Health MarketScan(®) Commercial and Medicare Supplemental databases. Patients (age ≥40, commercial; age ≥65, Medicare supplemental) had a first hospitalization with a primary COPD diagnosis between April 1, 2009 and June 30, 2011 (index hospitalization) and were continuously enrolled for 1 year before and 9 months after hospitalization. Patients were categorized according to pre-index and/or post-index pharmacy claims.

RESULTS: A total of 27,738 patients had an index hospitalization and met inclusion/exclusion criteria. Of those, 19,783 patients had COPD as a primary or secondary diagnosis during the year before index hospitalization and were included in the analysis. Approximately one quarter of the patients (26.32%) did not fill a prescription for an LABD or short-acting bronchodilator both 90 days before and 90 days after hospitalization. During the 90-day pre-index period, 40.57% of patients filled an LABD (with or without a short-acting bronchodilator) prescription. Over half of the patients (56.88%) filled an LABD prescription at some point during the 180-day post-index period, but, of those, a significantly greater proportion of patients filled an LABD prescription in the 1- to 90-day post-index period than in the 91- to 180-day post-index period (51.27% versus 43.66%; P<0.0001).

CONCLUSION: A significant proportion of COPD patients in this study did not fill an LABD prescription before hospitalization for COPD. Moreover, hospitalization did not appear to greatly impact LABD initiation. Lastly, patients who did not fill an LABD prescription within the first 90 days posthospitalization were not likely to fill an LABD prescription later. Taken together, the results of this study suggest that many patients with COPD are undertreated.

New combination treatments in the management of asthma: focus on fluticasone/vilanterol.

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Despite the 2007 National Asthma Education and Prevention Program Expert Panel 3 guidelines for the treatment of uncontrolled asthma, many patients with poorly controlled asthma still continue to tax the health care system. Controlling asthma symptoms and preventing acute exacerbations have been the foundation of care. Using long-term controller treatments such as inhaled corticosteroids (ICS) and inhaled long-acting beta2-agonists (LABAs) is a common approach.

While patient responses to recommended pharmacotherapy may vary, poor adherence to therapy also contributes to poor asthma control. A once-daily combination inhaler, such as fluticasone furoate, an ICS, in combination with vilanterol, a LABA, offers increased convenience and potential improved adherence, which should result in enhanced clinical outcomes and reduced exacerbations. The ICS/LABA combination inhaler of fluticasone furoate and vilanterol is currently approved in the United States for use in the maintenance of chronic obstructive pulmonary disease and to reduce exacerbations.

This paper reviews the expanding literature on the efficacy of fluticasone furoate and vilanterol in treating asthma.

The allergic emergency - management of severe allergic reactions.

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The allergic emergency - management of severe allergic reactions.

J Dtsch Dermatol Ges. 2014 May;12(5):379-88

Authors: Werner-Busse A, Zuberbier T, Worm M

Abstract
Anaphylaxis is characterized by the sudden onset of acute allergic symptoms involving two or more organ systems. An acute allergic emergency is a challenge for physicians due to its life-threatening potential. The incidence of anaphylactic reactions has increased in recent years. Most frequent elicitors of mast cell and primarily histamine dependent anaphylactic reactions are food, insect venom or drugs. Allergic -reactions are graded into four groups according to the classification by Ring and Messmer; grade I is defined by the onset of cutaneous symptoms only whereas grade IV is characterized by cardiovascular shock as well as cardiac and/or respiratory arrest. The treatment of allergic reactions should be guided by the severity of the reaction. Initially an intramuscular epinephrine injection into the lateral thigh should be given if cutaneous, mucosal and cardiovascular/respiratory symptoms occur. Additionally, the patient should receive intravenous antihistamines and corticosteroids. For self-treatment in the case of an allergic emergency, oral antihistamines and corticosteroids should be prescribed to the patient.

PMID: 24673732 [PubMed - in process]

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