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LAMA–LABA therapy may be preferred to ICS–LABA for patients with COPD

Illustration of human lungs and an inhaler

According to a recent paper in JAMA Internal Medicine, clinical guidelines for treatment of COPD recommend inhalers containing long-acting muscarinic antagonists (LAMAs) and long-acting β-agonists (LABAs) over inhalers containing inhaled corticosteroids (ICSs) and LABAs. However, data from randomized clinical trials comparing these combination inhalers have been conflicting,

Feldman and colleagues from Brigham and Women’s Hospital and Harvard Medical School (Boston) conducted a propensity score–matched cohort study to determine which inhalers are associated with the least incidence of exacerbations and pneumonia hospitalizations.

The study, published online on May 22, 2023, included over 137,000 patients from Optum’s Clinformatics Data Mart, a large commercial insurance–claims database, who had a diagnosis of COPD and filled a new prescription for a combination LAMA–LABA (aclidinium/formoterol, glycopyrronium/formoterol, glycopyrronium/indacaterol, tiotropium/olodaterol, or umeclidinium/vilanterol) or ICS–LABA inhaler (budesonide/formoterol, fluticasone/salmeterol, fluticasone/vilanterol, or mometasone/formoterol) between January 1, 2014, and December 31, 2019. Patients younger than 40 years were excluded, as were those with a prior diagnosis of asthma.

Over 30,000 matched pairs were identified for the primary analysis, which indicated that LAMA–LABA use was associated with an 8% reduction in the rate of first moderate or severe COPD exacerbation and a 20% reduction in the rate of first pneumonia hospitalization, compared with ICS–LABA use.

The authors indicated that these findings were robust across a range of prespecified subgroup and sensitivity analyses. ■

Tecovirimat effective in treating patients with both HIV and mpox

Tecovirimat molecule

Preliminary data have shown that tecovirimat, a novel antiviral approved for the treatment of human smallpox, can be effective in patients with mpox. Although it has not been approved by FDA for treatment of mpox, CDC recommends that it be considered for use in patients with comorbid diseases and those with severely compromised immunity, such as patients with HIV.

 In a recent study published in the May 2023 issue of Annals of Internal Medicine, researchers from Columbia University Medical Center, NewYork-Presbyterian Hospital, and Weill Cornell Medicine, compared mpox treatment outcomes in patients with HIV and those who are HIV negative.

The retrospective cohort study included 196 patients treated with tecovirimat from June 20, 2022, to August 29, 2022, at two academic medical centers in New York City. Of the 154 patients who tested positive for mpox, 72 also tested positive for HIV.

Results of the study showed no difference in treatment outcomes, including days to improvement or rate of persistent symptoms between the two groups. Nonsevere adverse effects were observed in 22% of the participants and the two groups had similar rates of hospitalization, indications for treatment, and co-occurring infections.

The authors concluded that although the future incidence and demographic features of mpox infection outbreak are unclear, a better understanding of both disease progression and treatment in people who bear the greatest burden of disease to date, primarily men who have sex with men and those with HIV, is critically important. They believe that tecovirimat is a promising treatment whose efficacy will hopefully be borne out in future rigorous studies. ■

Standardized procedure for periprocedural DOAC use in patients with AFib

Illustration of a detail of heart muscle strands

Discrepancies remain in periprocedural DOAC recommendations for patients with AFib undergoing elective surgery. In an effort to develop a standard procedure, Alan N. Barkun, MD, and colleagues at several international institutions conducted a cohort study among adult patients receiving a DOAC (apixaban, rivaroxaban, or dabigatran) for AFib who were scheduled for an elective procedure or surgery.

The study, published in the May 2023 issue of the American Journal of Gastroenterology, included 556 patients undergoing digestive endoscopy. Most of the patients underwent colonoscopies (63.3%) or gastroscopies (14.0%), with 18.9% having both on the same procedural day. Standardized periprocedural management consisted of DOAC interruption 1 day pre-endoscopy with resumption 1 day after procedure at low-moderate risk of bleeding or 2 days after procedure in patients with a high bleeding risk. Thirty-day outcomes included GI bleeding, thromboembolic events, and mortality.

Results of the study showed that patients with AFib undergoing DOAC therapy interruption for elective digestive endoscopy experienced low rates of arterial thromboembolism and major bleeding. Four patients (0.7%) experienced an arterial thromboembolic event within 30 days, GI bleeding events occurred in 2.5% of patients with major GI bleeding in 0.9% of patients. Three patients (0.5%) died after the endoscopy.

The authors concluded that this strategy should be considered for most patients with AFib who undergo elective endoscopic procedures.

Tirofiban shown to be effective for treatment of stroke

A senior citizen walks a golden retriever dog while using a walker

Recent observational studies have suggested that the glycoprotein IIb/IIIa receptor inhibitor tirofiban may be effective in selected patients with acute ischemic stroke. However, the use of tirofiban in patients with no evidence of complete occlusion of large- or medium-sized vessels has not been extensively studied.

The RESCUE BT2 investigators conducted a multicenter trial in China that evaluated the efficacy of tirofiban versus aspirin in patients with ischemic stroke without occlusion of large- or medium-sized vessels and with an NIH Health Stroke Scale score of 5 or more and at least one moderately to severely weak limb. The study was published in the June 1, 2023, issue of NEJM.

Patients were assigned to receive I.V. tirofiban (plus an oral placebo) or 100 mg oral aspirin (plus I.V. placebo) for 2 days; all patients then received oral aspirin until day 90. The primary efficacy end point was an excellent outcome, defined as a score of 0 or 1 on the modified Rankin scale at 90 days. The primary safety end points were death and symptomatic intracranial hemorrhage.

Results of the trial showed that 29.1% of the patients treated with tirofiban had a score of 0 or 1 on the modified Rankin scale at 90 days compared with 22.2% of the patients treated with aspirin. The incidence of symptomatic intracranial hemorrhage was 1.0% in the tirofiban group and 0% in the aspirin group. Mortality was similar in the two groups.

The authors concluded that the use of I.V. tirofiban was associated with a greater likelihood of an excellent outcome than low-dose aspirin. Incidences of intracranial hemorrhages were low but slightly higher with tirofiban. ■



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