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    <recommendedItem id="20090101_19_3557"
                     title="CHEST: Novel LABA Improves Lung Function in COPD (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/CHEST/tb/16823?impressionId=1265756075279"
                     
      SAN DIEGO  --  Indacaterol, an investigational long-acting beta&lt;sub&gt;2&lt;/sub&gt;-agonist, showed benefits over both placebo and salmeterol (Serevent) for moderate-to-severe chronic obstructive pulmonary disease (COPD) in a randomized trial, researchers reported here.&lt;br&gt;
&lt;br&gt;Through 26 weeks, the drug significantly improved bronchodilation, health status, and dyspnea over both control arms, although the benefits reached clinical importance over the placebo group only, according to Oliver Kornmann, MD, of Mainz University Hospital in Germany.&lt;br&gt;
&lt;br&gt;Indacaterol &quot;shows a trend toward improvement over salmeterol,&quot; he reported at the American College of Chest Physicians meeting.&lt;/p&gt;
&lt;p&gt;At the very least, he said, if indacaterol is approved by regulators, it could be a viable alternative to salmeterol for COPD.&lt;/p&gt;
&lt;p&gt;He said indacaterol was awaiting approval by the European Medicines Agency within the next three months, although he didn&apos;t know the drug&apos;s status in the U.S.&lt;/p&gt;
&lt;p&gt;The INLIGHT-2 study was a randomized, double-blind, placebo-controlled trial that compared once-daily treatment with 150 mcg of indacaterol, twice-daily treatment with 50 mcg of salmeterol, and placebo. A total of 998 patients were randomized in equal numbers to each group.&lt;/p&gt;
&lt;p&gt;The mean age of the patients was 63.5. Post-albuterol FEV&lt;sub&gt;1&lt;/sub&gt; was 53.4% of the predicted value, and the ratio of FEV&lt;sub&gt;1&lt;/sub&gt; to FVC was 53%. About 25% of the patients were female.&lt;/p&gt;
&lt;p&gt;Concomitant use of Inhaled corticosteroids was allowed.&lt;/p&gt;
&lt;p&gt;The primary endpoint was the 24-hour postdose FEV&lt;sub&gt;1&lt;/sub&gt; after 12 weeks of treatment.&lt;/p&gt;
&lt;p&gt;At 12 weeks, this value was 170 mL higher for indacaterol than for placebo and 60 mL higher than for salmeterol (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). Salmeterol caused significant improvement over placebo as well (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;The findings at 26 weeks were similar.&lt;/p&gt;
&lt;p&gt;Health status according to St. George&apos;s Respiratory Questionnaire was improved at 12 weeks with both indacaterol and salmeterol compared with placebo (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;With indacaterol, there was a clinically important difference of 6.3 points versus placebo. Any difference greater than 4 points is considered clinically meaningful, Kornmann said.&lt;/p&gt;
&lt;p&gt;The score with indacaterol was 2.1 points higher than with salmeterol (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05), falling short of the threshold for a clinically meaningful finding.&lt;/p&gt;
&lt;p&gt;At 26 weeks, health status with indacaterol remained significantly better than with placebo (5 points, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), but not better than treatment with salmeterol.&lt;/p&gt;
&lt;p&gt;At 12 and 26 weeks, both indacaterol and salmeterol improved dyspnea compared with placebo (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). Indacaterol was statistically superior to salmeterol at 12 weeks (&lt;em&gt;P&lt;/em&gt;=0.015), but not at 26 weeks.&lt;/p&gt;
&lt;p&gt;Both of the active medications reduced the proportion of days spent without the need for albuterol rescue (60% with indacaterol and 55% with salmeterol versus 42% with placebo, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for both). Indacaterol was statistically superior to salmeterol (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05).&lt;/p&gt;
&lt;p&gt;The rate of adverse events was slightly higher for indacaterol (51.2%) than for salmeterol (46%) or placebo (47%).&lt;/p&gt;
&lt;p&gt;The most common events were a worsening of COPD (18%, 15%, and 19%, respectively) and nasopharyngitis (7%, 9%, and 6%, respectively).&lt;/p&gt;
&lt;p&gt;Upper respiratory tract infections were more common in the indacaterol group than in the other two groups, a safety signal that had not been seen in previous indacaterol trials, Kornmann said.&lt;/p&gt;
&lt;p&gt;He said the reasons for the increase are unclear, but that it&apos;s likely a result of &quot;an imbalance by chance.&quot;&lt;/p&gt;
&lt;p&gt;Serious adverse events were more common with indacaterol than salmeterol (8.8% versus 5.7%), perhaps driven by the difference in upper respiratory tract infections, Kornmann said.&lt;/p&gt;
&lt;p&gt;There were five deaths reported  --  one each in the two active-treatment groups and three in the placebo group  --  although none was attributed to treatment.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by Novartis Pharma AG.&lt;/p&gt;&lt;p&gt;Kornmann has presented at symposia sponsored by AstraZeneca, Boehringer, GlaxoSmithKline, Novartis, and Pfizer, and has received consulting fees from Altana, Boehringer, and Novartis.&lt;/p&gt;&lt;p&gt;Four of the study authors are employed by Novartis.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3582"
                     title="CHEST: Uncertainty Surrounds Opioids in Advanced COPD (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/CHEST/tb/16853?impressionId=1265756075279"
                     
      &lt;p&gt;SAN DIEGO  --  Patients with advanced chronic obstructive pulmonary disease (COPD) may not be getting effective treatment for dyspnea toward the end of life, researchers reported here.&lt;/p&gt;
&lt;p&gt;A retrospective review of administrative claims data showed that patients with advanced COPD were significantly less likely to receive morphine in the last three months of life than those with terminal lung cancer (OR 2.36, 95% CI 1.52 to 3.67), according to Donna Goodridge, PhD, of the University of Saskatchewan in Saskatoon.&lt;/p&gt;
&lt;p&gt;They were also less likely to receive palliative care at home (2.8% versus 37.4%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.005), and palliative care itself was associated with an increased likelihood of receiving morphine in the months before death (OR 2.64, 95% CI 1.72 to 4.06), Goodridge said at the American College of Chest Physicians meeting.&lt;/p&gt;
&lt;p&gt;She said the findings underscore the need for further research.&lt;/p&gt;
&lt;p&gt;&quot;We need to explore the efficacy and safety of opioid use for relief of dyspnea at the end of life in persons with COPD,&quot; she said. &quot;And we also need to assess patient, family, and clinician experiences with opioid use for dyspnea at the end of life for those people dying of COPD.&quot;&lt;/p&gt;
&lt;p&gt;Dyspnea is the most burdensome symptom and a source of disability in end-stage COPD, Goodridge said, and it doesn&apos;t respond to conventional therapies in 56% to 98% of patients.&lt;/p&gt;
&lt;p&gt;Opioids are commonly used to treat dyspnea in patients with terminal cancer, but Goodridge said she was surprised to see that there wasn&apos;t a very good management strategy in COPD.&lt;/p&gt;
&lt;p&gt;Low doses of opioids could relieve dyspnea in COPD patients by reducing total ventilation, increasing ventilatory efficiency with exercise, reducing responses to hypoxia/hypercapnia, and reducing the drive to breathe, Joanne Young, a registered respiratory therapist at Dalhousie University in Halifax, Nova Scotia, and colleagues noted in a separate presentation at the meeting.&lt;/p&gt;
&lt;p&gt;The drugs might also affect bronchoconstriction, they said in a poster session.&lt;/p&gt;
&lt;p&gt;A 2002 meta-analysis in &lt;em&gt;Thorax&lt;/em&gt; found that both oral and parenteral opioids had a positive effect on breathlessness (&lt;em&gt;P&lt;/em&gt;=0.0008) in all patient groups, including those with COPD. But how often patients with COPD are treated with opioids has not been well studied.&lt;/p&gt;
&lt;p&gt;So Goodridge and her colleagues examined administrative data from the Saskatchewan Health Ministry on all patients who died during 2004 of lung cancer (433 patients) or COPD (602 patients).&lt;/p&gt;
&lt;p&gt;Patients with COPD were less likely to die in the hospital and more likely to die in a long-term care facility (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05).&lt;/p&gt;
&lt;p&gt;In the last three months of life, more patients with lung cancer received a prescription for morphine (31% versus 9%).&lt;/p&gt;
&lt;p&gt;The strongest predictor of receiving morphine was palliative care at home, which, though more frequent in patients with lung cancer, was surprisingly underused in both groups, Goodridge said.&lt;/p&gt;
&lt;p&gt;&quot;This is something that I think we may need to explore further,&quot; she said.&lt;/p&gt;
&lt;p&gt;The study by Young and colleagues explored possible reasons at the clinical level for the infrequent use of opioids in patients with advanced COPD.&lt;/p&gt;
&lt;p&gt;The researchers interviewed 10 family physicians and eight respiratory therapists in the province of New Brunswick about their attitudes toward prescribing the medications for the relief of dyspnea.&lt;/p&gt;
&lt;p&gt;Although the clinicians all agreed that the control of dyspnea was the biggest challenge in treating patients with end-stage COPD, there was reluctance in using opioids unless death was imminent.&lt;/p&gt;
&lt;p&gt;They cited concerns about respiratory depression, as well as about a lack of education and guidance from professional societies.&lt;/p&gt;
&lt;p&gt;Two younger family physicians who received training in palliative care during their residencies expressed more comfort in using opioids for these patients.&lt;/p&gt;
&lt;p&gt;Like Goodridge, Young and colleagues called for further research regarding the use of opioids for relieving dyspnea at the end of life in patients with COPD.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study by Young and colleagues received funding from the Atlantic Health Sciences Corporation Health Promotion and Research Fund.&lt;/p&gt;&lt;p&gt;None of the authors of either of the studies reported any conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_578"
                     title="CHEST: Americans Treated Suboptimally for Obstructive Lung Disease"
                     score="-0.005"
                     href="