Editorials
16 Boyd IW, Mathew TH, Thomas MC. Cox-2 inhibitors and renal failure: the triple whammy revisited. Med J Aust 2000; 173: 274. 17 Descombes E, Fellay G. End-stage renal failure after irbesartan prescription in a diabetic patient with previously stable chronic renal insufficiency. Ren Fail 2000; 22(6): 815–21. 18 Onuigbo MAC, Onuigbo NT. Late onset renal failure from angiotensin blockade (LORFFAB): a prospective thirty-month Mayo Health System clinic experience. Med Sci Monit 2005; 11(10): CR462–9. 19 Onuigbo MAC, Onuigbo NT. Late-onset renal failure from angiotensin blockade (LORFFAB) in 100 CKD patients. Int Urol Nephrol 2008; 40(1): 233–9. 20 Onuigbo MAC, Onuigbo NT. Late onset azotemia from RAAS blockade in CKD patients with normal renal arteries and no precipitating risk factors. Ren Fail 2008; 30(1): 73–80.
21 Onuigbo MAC, Achebe NJ. Late onset renal failure from angiotensin blockade (LORFFAB) – the results of a Mayo Clinic Health System Angiotensin Inhibition Withdrawal Study: a clarion call for more preventative nephrology, also called renoprevention. In: Onuigbo MAC, ed. ACE inhibitors: Medical Uses, Mechanisms of Action, Potential Adverse Effects and Related Topics, vol. 1. New York, NY: NOVA Publishers, 2013: 75–90. 22 Ahmed AK, Kamath NS, El Kossi M, El Nahas AM. The impact of stopping inhibitors of the reninangiotensin system in patients with advanced chronic kidney disease. Nephrol Dial Transplant 2010; 25(12): 3977–82. 23 Goncßalves AR, Khwaja A, Ahmed AK, El Kossi M, El Nahas M. Stopping renin-angiotensin system inhibitors in chronic kidney disease: predictors of response. Nephron Clin Pract 2011; 119(4): c348–54.
513
24 Gottlieb SS, Abraham W, Butler J et al. The prognostic importance of different definitions of worsening renal function in congestive heart failure. J Card Fail 2002; 8(3): 136–41. 25 Onuigbo MAC. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med 2009; 169(19): 1810; author reply 1810–1.
Disclosure None. doi: 10.1111/ijcp.12595
EDITORIAL
COPD: early diagnosis and treatment to slow disease progression Linked Comment: Welte et al. Int J Clin Pract 2015; 69: 336–49.
Chronic obstructive pulmonary disease (COPD) is defined by the Global initiative for chronic Obstructive Lung Disease (GOLD) as a common, preventable and treatable disease characterised by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases (1). The progressive nature of COPD was well described in the seventies of the last century by Fletcher and Peto (2). Fletcher and Peto also demonstrated that smoking cessation abated the lung function decline that is characteristic of COPD (2). Subsequent work has also shown that smoking cessation in addition to abating lung function decline also reduces mortality rates albeit mortality rates remaining relatively higher than among non-smokers (3,4). Prognosis of COPD depends on severity of disease with those with more severe disease more prone to more severe exacerbations, hospitalizations, respiratory failure and death (4). Patients with milder disease have less risk of the above but are at greater risk of disease progression (5).Therefore, treatment goals should depend on these likely prognostic courses. Slowing disease progression is a key goal in management of milder forms of COPD. Therefore, the article by Weltes et al. (6) in this issue of the journal
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69, 5, 509–514
that presents an evidence-based non-systematic review of the treatment options for slowing COPD disease progression among patients with milder disease is worthwhile and timely. Generally, the options for slowing disease progression in this group of patients include smoking cessation and pharmacotherapy (long acting bronchodilators, inhaled corticosteroids and a combination of inhaled steroids and long acting bronchodilators) (2,3,5,7–9). Although smoking cessation has been recognised for decades as pivotal for slowing COPD disease progression, pharmacotherapy has come to be recognised as a useful treatment in the last few years (10,11). The authors have summarised these recent and old studies very well in their review. In general, the effects of pharmacotherapy in patients with mild COPD on longterm outcomes are limited and not very well investigated. Because the authors did not perform a formal systematic review with a clear approach that defines the patient population, intervention, comparator and outcome (PICO), the usefulness of this extensive description of the literature has been reduced. In addition further reviews and original research articles are needed to evaluate the impact of pharmacotherapy on long-term outcomes such as mortality and burden of disease as has been the case with
Slow disease progression in COPD
514
Editorials
smoking cessation. The impact of extended longterm pharmacotherapy in comparison to smoking cessation and in comparison to symptomatic therapy alone needs to be further addressed. This is important to assess the balance between the adverse effects of long-term drug use especially long acting bronchodilators bearing in mind that in milder disease this maintenance therapy will have to be taken for longer periods of time. Studies will also be needed to evaluate if indeed maintenance therapy has to be taken for life or drug holidays or breaks can be given. Furthermore, the benefit of these pharmacotherapies among patients with COPD as a result of other emerging risk factors such as biomass smoke needs to be evaluated. Biomass smoke-related COPD is currently estimated to be the leading cause of
References 1 Global Strategy for the Diagnosis, Management and Treatment of Chronic Obstructive Pulmonary Disease. Jan 2014 Update. http://www.goldcopd.org/ uploads/users/files/GOLD_Report_2014_Jan23.pdf (accessed December 13 2014). 2 Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J 1977; 1: 1645. 3 Pelkonen M, Tukiainen H, Tervahauta M et al. Pulmonary function, smoking cessation and 30 year mortality in middle aged Finnish men. Thorax 2000; 55: 746–50. 4 Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE. The effects of a smoking cessation intervention on 14.5-year mortality a randomized clinical trial. Ann Intern Med 2005; 142: 233–9. 5 Anthonisen NR, Connett JE, Murray RP. Smoking and lung function of Lung Health Study participants after 11 years. Am J Respir Crit Care Med 2002; 166: 675–9. 6 Welte T, Vogelmeier C, Papi A. COPD: early diagnosis and treatment to slow disease progression. Int J Clin Pract 2015; 69: 336–49.
COPD worldwide (12). In a survey conducted in Uganda, about half of COPD patients were female non-smokers (13). In the same survey, more than 78% of the COPD was mild disease but healthcare utilisation and exacerbations were high (13). Therefore, effective interventions for milder COPD disease are urgently needed especially in low and middle income countries. T. van der Molen,1 B. J. Kirenga1,2 Groningen Research centre in Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands 2 Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda Email: [email protected] 1
7 Anthonisen NR, Connett JE, Kiley JP et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1: the Lung Health Study. JAMA 1994; 272: 1497–505. 8 Decramer M, Rossi A, Lawrence D, McBryan D. Indacaterol therapy in patients with COPD not receiving other maintenance treatment. Respir Med 2012; 106: 1706–14. 9 Decramer M, Celli B, Kesten S, Lystig T, Mehra S, Tashkin DP. Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT): a prespecified subgroup analysis of a randomised controlled trial. Lancet 2009; 374: 1171–8. 10 Calverley P, Boonsawat W, Cseke Z, Zhong N, Peterson S, Olsson H. Maintenance therapy with budesonide and formoterol in chronicobstructive pulmonary disease. Eur Respir J 2003; 22: 912–9. 11 Decramer M, Dahl R, Kornmann O, Korn S, Lawrence D, McBryan D. Effects of long-acting bronchodilators in COPD patients according to
COPD severity and ICS use. Respir Med 2013; 107: 223–32. 12 Salvi S, Barnes PJ. Is exposure to biomass smoke the biggest risk factor for COPD globally? Chest 2010; 138: 3–6. 13 van Gemert F, Kirenga B, Chavannes N et al. Prevalence of COPD and Its Risk Factors in a Rural Area of Uganda: FRESH AIR Uganda. Abstract for IPCRG conference 2013. https://www.theipcrg.org/ download/attachments/688217/GRIACposter+ERS +final.pdf?version=1&modificationDate=13827934 03000 (accessed April 9 2014).
Disclosure None. doi: 10.1111/ijcp.12622
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69, 5, 509–514
16 Boyd IW, Mathew TH, Thomas MC. Cox-2 inhibitors and renal failure: the triple whammy revisited. Med J Aust 2000; 173: 274. 17 Descombes E, Fellay G. End-stage renal failure after irbesartan prescription in a diabetic patient with previously stable chronic renal insufficiency. Ren Fail 2000; 22(6): 815–21. 18 Onuigbo MAC, Onuigbo NT. Late onset renal failure from angiotensin blockade (LORFFAB): a prospective thirty-month Mayo Health System clinic experience. Med Sci Monit 2005; 11(10): CR462–9. 19 Onuigbo MAC, Onuigbo NT. Late-onset renal failure from angiotensin blockade (LORFFAB) in 100 CKD patients. Int Urol Nephrol 2008; 40(1): 233–9. 20 Onuigbo MAC, Onuigbo NT. Late onset azotemia from RAAS blockade in CKD patients with normal renal arteries and no precipitating risk factors. Ren Fail 2008; 30(1): 73–80.
21 Onuigbo MAC, Achebe NJ. Late onset renal failure from angiotensin blockade (LORFFAB) – the results of a Mayo Clinic Health System Angiotensin Inhibition Withdrawal Study: a clarion call for more preventative nephrology, also called renoprevention. In: Onuigbo MAC, ed. ACE inhibitors: Medical Uses, Mechanisms of Action, Potential Adverse Effects and Related Topics, vol. 1. New York, NY: NOVA Publishers, 2013: 75–90. 22 Ahmed AK, Kamath NS, El Kossi M, El Nahas AM. The impact of stopping inhibitors of the reninangiotensin system in patients with advanced chronic kidney disease. Nephrol Dial Transplant 2010; 25(12): 3977–82. 23 Goncßalves AR, Khwaja A, Ahmed AK, El Kossi M, El Nahas M. Stopping renin-angiotensin system inhibitors in chronic kidney disease: predictors of response. Nephron Clin Pract 2011; 119(4): c348–54.
513
24 Gottlieb SS, Abraham W, Butler J et al. The prognostic importance of different definitions of worsening renal function in congestive heart failure. J Card Fail 2002; 8(3): 136–41. 25 Onuigbo MAC. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med 2009; 169(19): 1810; author reply 1810–1.
Disclosure None. doi: 10.1111/ijcp.12595
EDITORIAL
COPD: early diagnosis and treatment to slow disease progression Linked Comment: Welte et al. Int J Clin Pract 2015; 69: 336–49.
Chronic obstructive pulmonary disease (COPD) is defined by the Global initiative for chronic Obstructive Lung Disease (GOLD) as a common, preventable and treatable disease characterised by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases (1). The progressive nature of COPD was well described in the seventies of the last century by Fletcher and Peto (2). Fletcher and Peto also demonstrated that smoking cessation abated the lung function decline that is characteristic of COPD (2). Subsequent work has also shown that smoking cessation in addition to abating lung function decline also reduces mortality rates albeit mortality rates remaining relatively higher than among non-smokers (3,4). Prognosis of COPD depends on severity of disease with those with more severe disease more prone to more severe exacerbations, hospitalizations, respiratory failure and death (4). Patients with milder disease have less risk of the above but are at greater risk of disease progression (5).Therefore, treatment goals should depend on these likely prognostic courses. Slowing disease progression is a key goal in management of milder forms of COPD. Therefore, the article by Weltes et al. (6) in this issue of the journal
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69, 5, 509–514
that presents an evidence-based non-systematic review of the treatment options for slowing COPD disease progression among patients with milder disease is worthwhile and timely. Generally, the options for slowing disease progression in this group of patients include smoking cessation and pharmacotherapy (long acting bronchodilators, inhaled corticosteroids and a combination of inhaled steroids and long acting bronchodilators) (2,3,5,7–9). Although smoking cessation has been recognised for decades as pivotal for slowing COPD disease progression, pharmacotherapy has come to be recognised as a useful treatment in the last few years (10,11). The authors have summarised these recent and old studies very well in their review. In general, the effects of pharmacotherapy in patients with mild COPD on longterm outcomes are limited and not very well investigated. Because the authors did not perform a formal systematic review with a clear approach that defines the patient population, intervention, comparator and outcome (PICO), the usefulness of this extensive description of the literature has been reduced. In addition further reviews and original research articles are needed to evaluate the impact of pharmacotherapy on long-term outcomes such as mortality and burden of disease as has been the case with
Slow disease progression in COPD
514
Editorials
smoking cessation. The impact of extended longterm pharmacotherapy in comparison to smoking cessation and in comparison to symptomatic therapy alone needs to be further addressed. This is important to assess the balance between the adverse effects of long-term drug use especially long acting bronchodilators bearing in mind that in milder disease this maintenance therapy will have to be taken for longer periods of time. Studies will also be needed to evaluate if indeed maintenance therapy has to be taken for life or drug holidays or breaks can be given. Furthermore, the benefit of these pharmacotherapies among patients with COPD as a result of other emerging risk factors such as biomass smoke needs to be evaluated. Biomass smoke-related COPD is currently estimated to be the leading cause of
References 1 Global Strategy for the Diagnosis, Management and Treatment of Chronic Obstructive Pulmonary Disease. Jan 2014 Update. http://www.goldcopd.org/ uploads/users/files/GOLD_Report_2014_Jan23.pdf (accessed December 13 2014). 2 Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J 1977; 1: 1645. 3 Pelkonen M, Tukiainen H, Tervahauta M et al. Pulmonary function, smoking cessation and 30 year mortality in middle aged Finnish men. Thorax 2000; 55: 746–50. 4 Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE. The effects of a smoking cessation intervention on 14.5-year mortality a randomized clinical trial. Ann Intern Med 2005; 142: 233–9. 5 Anthonisen NR, Connett JE, Murray RP. Smoking and lung function of Lung Health Study participants after 11 years. Am J Respir Crit Care Med 2002; 166: 675–9. 6 Welte T, Vogelmeier C, Papi A. COPD: early diagnosis and treatment to slow disease progression. Int J Clin Pract 2015; 69: 336–49.
COPD worldwide (12). In a survey conducted in Uganda, about half of COPD patients were female non-smokers (13). In the same survey, more than 78% of the COPD was mild disease but healthcare utilisation and exacerbations were high (13). Therefore, effective interventions for milder COPD disease are urgently needed especially in low and middle income countries. T. van der Molen,1 B. J. Kirenga1,2 Groningen Research centre in Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands 2 Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda Email: [email protected] 1
7 Anthonisen NR, Connett JE, Kiley JP et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1: the Lung Health Study. JAMA 1994; 272: 1497–505. 8 Decramer M, Rossi A, Lawrence D, McBryan D. Indacaterol therapy in patients with COPD not receiving other maintenance treatment. Respir Med 2012; 106: 1706–14. 9 Decramer M, Celli B, Kesten S, Lystig T, Mehra S, Tashkin DP. Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT): a prespecified subgroup analysis of a randomised controlled trial. Lancet 2009; 374: 1171–8. 10 Calverley P, Boonsawat W, Cseke Z, Zhong N, Peterson S, Olsson H. Maintenance therapy with budesonide and formoterol in chronicobstructive pulmonary disease. Eur Respir J 2003; 22: 912–9. 11 Decramer M, Dahl R, Kornmann O, Korn S, Lawrence D, McBryan D. Effects of long-acting bronchodilators in COPD patients according to
COPD severity and ICS use. Respir Med 2013; 107: 223–32. 12 Salvi S, Barnes PJ. Is exposure to biomass smoke the biggest risk factor for COPD globally? Chest 2010; 138: 3–6. 13 van Gemert F, Kirenga B, Chavannes N et al. Prevalence of COPD and Its Risk Factors in a Rural Area of Uganda: FRESH AIR Uganda. Abstract for IPCRG conference 2013. https://www.theipcrg.org/ download/attachments/688217/GRIACposter+ERS +final.pdf?version=1&modificationDate=13827934 03000 (accessed April 9 2014).
Disclosure None. doi: 10.1111/ijcp.12622
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69, 5, 509–514
