Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP- EXPO Recommendations-2024).

INTRODUCTION: Pneumococcal diseases pose a significant public health concern in India, with substantial morbidity and mortality, with the elderly and those with coexisting medical conditions being most at risk. Pneumococcus was also seen to be one of the main reasons for co-infection, pneumonia and complications in COVID. Current guidelines recommend vaccination for specific adult populations, but there is a lack of uniformity and guidance on risk stratification, prioritisation and optimal timing. METHODS: Nation Against Pneumococcal Infections - Expert Panel Opinion (NAP-EXPO) is a panel convened to review and update recommendations for adult pneumococcal vaccination in India. The panel of 23 experts from various medical specialties engaged in discussions and evidence-based reviews, discussed appropriate age for vaccination, risk stratification for COPD and asthma patients, vaccination strategies for post-COVID patients, smokers and diabetics, as well as methods to improve vaccine awareness and uptake. OUTCOME: The NAP-EXPO recommends the following for adults: All healthy individuals 60 years of age and above should receive the pneumococcal vaccine; all COPD patients, regardless of severity, high-risk asthma patients, post-COVID cases with lung fibrosis or significant lung damage, should be vaccinated with the pneumococcal vaccine; all current smokers and passive smokers should be educated and offered the pneumococcal vaccine, regardless of their age or health condition; all diabetic individuals should receive the pneumococcal vaccine, irrespective of their diabetes control. Strategies to improve vaccine awareness and uptake should involve general practitioners (GPs), primary health physicians (PHPs) and physicians treating patients at high risk of pneumococcal disease. Advocacy campaigns should involve media, including social media platforms. CONCLUSION: These recommendations aim to enhance pneumococcal vaccination coverage among high-risk populations in India in order to ensure a reduction in the burden of pneumococcal diseases, in the post-COVID era. There is a need to create more evidence and data to support the recommendations that the vaccine will be useful to a wider range of populations, as suggested in our consensus.

Edema India: Executive Summary of Screening, Diagnosis, and Management of Edema.

The management of edema requires a systematic approach to screening, diagnosis, and treatment, with an essential initial assessment to differentiate between generalized and localized edema. The Association of Physicians of India (API) aimed to develop the first Indian Edema Consensus (Edema India), offering tailored recommendations for screening, diagnosing, and managing edema based on the insights from the expert panel. The panel suggested when evaluating edema symptoms, important factors to consider include the patient's current illness, medical history, risk factors, family history, and medications. Key diagnostic investigations for edema include complete blood count, cardiovascular imaging and markers, deep vein thrombosis (DVT) assessment, along with renal, hepatic, and thyroid function tests. Edema management involves a combination of pharmacologic and nonpharmacologic interventions, including limb elevation, physiotherapy, compression therapy, fluid removal, diuretics (loop diuretics: first-line therapy), and a sodium-restricted diet. The panel believed that educating patients could foster a preventive mindset, helping to prevent the worsening of edema.

Screening for Lung Cancer in India: Expert Opinion Statement.

Lung cancer (LC) has the highest rate of disability-adjusted life years (DALY) of all cancers in India. A large majority of patients with LC present with advanced disease, resulting in poor survival rates. Early diagnosis can improve survival outcomes as the patients can be treated with curative intent. The National Lung Screening Trial (NLST), in 53,454 persons at high risk for LC in the US, showed a 20% (95% confidence interval of 6.8-26.7; p = 0.004) relative reduction in LC-specific mortality in the patients screened with low-dose computed tomography (LDCT) compared with chest X-ray. To date, India does not have a formal LC screening (LCS) program. As a panel of experts, we reviewed a synthesis of a targeted literature search on the burden of LC, the current status of diagnosis of LC, barriers to early diagnosis, current referral pathways, LC risk patterns, use of artificial intelligence (AI) and risk calculators for risk assessment, and a multidisciplinary team (MDT) approach to diagnosis LC. We used the existing international LCS guidelines, data from published literature, and clinical experience to depict the characteristics of the population at risk of LC in India-young age (<40 years), smoking, especially the predominance of bidi smoking (an indigenous form of tobacco smoking), exposure to biomass fuel smoke, especially in rural women, and air pollution being the prominent features. LC in India is characterized by a higher rate of driver mutations and adenocarcinomatous histology. Here, we present the expert opinion on risk-based LCS in India and discuss the challenges, facilitators, and research priorities for the effective rollout of LCS in India.

Connecting the Dots: Hydration, Micronutrients, and Immunity.

Dehydration, often unnoticed, can occur in adults due to heat-related illnesses, viral infections, and upper respiratory tract infections, leading to deficits in fluids, electrolytes, and energy (FEE), even without diarrhea. This fluid deficit, in turn, impairs immunity at cellular and molecular levels. Physiologically, the immune system rapidly reacts to threats by adjusting its structural permeability, allowing water and small solutes to be passed, facilitated by proteins like aquaporins (AQPs). These AQPs are also essential for immune cell communication and adjustments of the cytoskeleton for functions like chemotaxis and phagocytosis. Apart from hydration, maintaining an optimal intake of essential micronutrients, including vitamins C and E, copper, zinc, and selenium, is also critical for supporting immune function and acting as antioxidants. Transient alterations in immune function caused by acute stressors or nondiarrheal conditions heighten vulnerability to coexisting illnesses, particularly cold and upper respiratory tract infections, while also elevating the likelihood of recurrent health issues. Supplementing fluids with known FEE content according to quality standards and enhanced taste is recommended during acute illness and until complete recovery. Thus, dehydration, caused by various acute conditions, can impair immunity and delay recovery. Prioritizing hydration and nutrition in healthcare and general settings is imperative, even when diarrhea is absent.

Defeating the Silent Enemy: Antimicrobial Resistance Looming as the Next Global Pandemic.

Antibiotics are the magic bullets that have saved millions worldwide. Enormous and irresponsible use of antibiotics has led to resistance to antibiotics, which is a matter of global health concern. The superbugs are responsible for life-threatening infections, treatment failure, and high mortality worldwide. The urgent healthcare threat caused by antimicrobial resistance (AMR) to nonfermenting gram-negative bacteria is being increasingly acknowledged worldwide. Antibiotic resistance found in organisms in hospital settings is now increasingly found in the community. Although antimicrobial stewardship requiring a multidisciplinary approach is developing rapidly at the hospital level, it needs more attention at the community level. New therapeutics are certainly required, but the major challenge is rapidly identifying resistant infections and tailoring treatment. This review highlights the crisis that reflects the current scenario of AMR, common resistant pathogens, and the major challenges in the fight against AMR. It also discusses potential methods and strategies to address the intricacies of antibiotic resistance.

Treatment challenges in the management of difficult-to-treat gram-positive infections: A consensus view apropos therapeutic role of novel anti-MRSA antibiotics, levonadifloxacin (IV) and alalevonadifloxacin (oral).

PURPOSE: Treatment of antibiotic-resistant Gram-positive infections (GPIs), including methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly difficult, particularly in patients with multiple co-morbidities who require antibiotics with greater safety and a consistent pharmacokinetic/pharmacodynamic (PK/PD) profile. Such difficult-to-treat GPIs are often associated with poor outcomes, extended hospital stay and increased expenditure. This can be partly attributed to the limited safety and aberrant PK/PD profile of existing anti-MRSA antibiotics. In this context, intravenous levonadifloxacin and its oral prodrug alalevonadifloxacin are novel anti-MRSA antibiotics that have significant advantages over conventional anti-Gram-positive antibiotics. The purpose of this paper was to generate a consensus on the optimal use of levonadifloxacin and alalevonadifloxacin for tackling resistant Gram-positive infections in patients with multiple co-morbidities. METHOD: Using a modified Delphi approach that combines critical appraisal of evidence and expert opinion, therapeutic use of levonadifloxacin and alalevonadifloxacin in various clinical scenarios and specific unmet conditions was deliberated. Fifteen expert members from medicine, critical-care, emergency, microbiology, and intensive-care disciplines participated and voted on 11 pre-conceived statements. When there was at least 70 % agreement, a consensus was reached. RESULTS: Following the voting, agreements were reached on 10 out of the 11 statements. Broadly, a consensus was reached in defining the therapeutic role of levonadifloxacin and alalevonadifloxacin in the treatment of various clinical indications involving resistant Gram-positive pathogens, including MRSA, in patients with co-morbidities, such as co-existing or increased risk for kidney dysfunction or hepatic disease and/or immunosuppression; also, in therapeutically challenging conditions caused by Gram-positive bacteria such as bacteraemia, bone and joint infection, diabetic foot infection, febrile neutropenia, and hospital-acquired pneumonia. CONCLUSIONS: This consensus supports the therapeutic use of levonadifloxacin and alalevonadifloxacin in the treatment of antibiotic-resistant GPIs, including those caused by MRSA and certain polymicrobial infections, in patients with multiple co-morbidities requiring drug with adequate safety and consistent efficacy.

Genomic revolution: Transforming tuberculosis diagnosis and treatment with the use of Whole Genome Sequencing - A consensus statement.

Tuberculosis (TB) is a preventable, treatable, and curable disease. However, in 2020, 9∙9 million people were estimated to have developed tuberculosis, and 1.5 million people were estimated to have died from it. Whereas in India, 2.6 million were diagnosed with TB and 436,000 succumbed to TB in 2019. India (26%) is the major contributor to the global drop in TB cases. The COVID-19 pandemic has substantially reduced access to services for the diagnosis and treatment of TB, resulting in an increase in deaths and a reversal in global progress. [1] Presently, TB incidence is falling at a rate of 2% per year, obstructed mainly by the rearing pandemic of drug-resistant tuberculosis (DRTB). Particularly concerning is multi-drug resistant TB (MDRTB), defined as resistance towards isoniazid (INH) and rifampicin (RIF). [2] The World Health Organization (WHO) targeted to reduce worldwide TB incidence by 90% until 2035. (1) Early initiation of effective treatment based on susceptibility patterns of the Mycobacterium tuberculosis complex (MTBC) is considered key to successful TB control in countries with high DRTB incidence. Worldwide MDRTB treatment outcomes are poor, with cure rates less than 60% (2) due to the lack of comprehensive Drug Susceptibility Testing (DST) in most high MDRTB burden countries. This is leading to the inadequate anti-TB activity of the provided regimens (3-5), unlike regimens advised for DST assure optimal results. (6) In addition to resistances to the established regimens, the resistance to the newer DRTB drugs is increasing. On World TB Day 2022, Academy of Advanced Medical Education, Thyrocare Technologies Limited and HyastackAnalytics - IITB along with expert pulmonologist and renowned physicians from India convened for an advisory board meeting in Delhi on 20th March 2022 to discuss the role of Whole Genome Sequencing (WGS) in the diagnosis and management of TB. Objectives and specific topics relating to WGS in MDRTB were discussed, each expert shared their views, which led to a group discussion with a commitment to putting the patient first, and increasing their collective efforts, the organizations recognized that it is possible to make this goal a reality. The organizations involved in the discussion have declared their commitment to engaging in collaborative efforts to tackle DRTB detection efficiently. They advocate for strengthening access to WGS TB services, controlling and preventing TB, improving surveillance and drug resistance management, and investing in research and development. This Round Table serves as a framework to build on and ensure that the goal of ending TB is achievable with WGS services wherever needed. Post discussion, a uniform consensus was said to be arrived if more than 80% board members agreed to the statement. The present paper is the outcome of aspects presented and discussed in the advisory board meeting.

Clinical Practice Guidelines for Management of Pain, Agitation, Delirium, Immobility, and Sleep Disturbance in the Intensive Care Unit: The ABCDEF Bundle.

It is crucial to prevent and manage intensive care unit (ICU) distress caused by a pentad of pain, agitation, delirium, immobility, and sleep disturbance (PADIS) to optimize immediate and longterm recovery and outcomes of critically ill patients. This clinical practice guideline provides an update on the prevention, management, and liberation of PADIS in adult ICU patients using an integrated, evidence-based, multidisciplinary ICU protocol: the ABCDEF bundle. ABCDEF bundle incorporates assessment, prevention, and management of pain; both spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT); choice of sedation and analgesia; delirium: assessment, prevention and management, and early mobility and exercise; family involvement and empowerment (ABCDEF) together as a PADIS care bundle. This is a multidimensional ICU liberation bundle which is a patient-oriented, holistic team approach to the management of critically ill patients aimed at reducing ICU distress and immediate and long-lasting consequences of PADIS.

INDIan Consensus on the mAnagemenT of cOugh at pRimary care setting (INDICATOR).

BACKGROUND: Cough has a prevalence of 9.6% globally and 5-10% in India. Though it is a reflex action, it affects an individual's quality of life (QoL) when uncontrolled. There was a need to create an integrated guidance document on managing cough focused on primary care physicians in the Indian setting. This consensus intends to bridge this gap by providing clinical recommendations to diagnose and manage cough in primary healthcare in India. MATERIALS AND METHODS: The modified Delphi method was used to arrive at a consensus on clinical statements. The panel comprised 10 experts, including pulmonologists, otolaryngologists, a pediatrician, and a general physician. The statements were discussed under the following domains: definition, etiology, diagnosis, and treatment. RESULTS: A total of 109 clinical statements were framed, with 75 reaching consensus, 13 reaching near consensus, and 21 reaching no consensus. The experts recommended empiric use of nonopioid antitussive agents for symptomatic relief of acute dry cough. The use of oral antihistamines, oral decongestants, or mucoactive agents as a part of fixed-dose combinations (FDCs) in cough associated with rhinitis or upper airway cough syndrome (UACS) can be considered for symptomatic relief. Maintaining good hydration is important to manage a productive cough. Codeine-based preparations are to be considered as a last resort in patients with an unexplained chronic cough when other treatments have failed. Additionally, insights were captured on red flag signs, nonpharmacologic therapy, special populations, and referral to higher centers. Experts have also proposed a management algorithm with an integrated care pathway approach for acute, subacute, and chronic coughs. CONCLUSION: The present consensus fills the existing need and may guide the physician to successfully diagnose and manage cough in the primary healthcare setting in India.

Proceedings of the expert consensus group meeting on herpes zoster disease burden and prevention in India: An opinion paper.

Herpes zoster (HZ) is a debilitating viral infection causing a dermatomal vesicular rash. Many known risk factors exist in India and adults >50 years of age may be especially susceptible to HZ. However, HZ is not a notifiable disease in India and data on incidence and disease burden is lacking. An Expert Consensus Group meeting was conducted with experts from relevant specialties to discuss HZ disease, its local epidemiology, and suggestions for implementing HZ vaccination in the Indian healthcare system. Currently, there is lack of patient awareness, poor reporting practices and general negligence in the treatment of the disease. HZ patients generally approach their general physicians or specialists for diagnosis, which is usually based on patient history and clinical symptoms. Recombinant zoster vaccine (RZV) has >90% efficacy and is recommended in adults ≥50 years of age to prevent HZ in the United States. Despite RZV being approved for use, it is not yet available in India. India has a growing elderly population with known risk factors for HZ like immunosuppression, and co-morbidities like diabetes and cardiovascular disease. This indicates the need for a targeted immunization program in India. Meeting also emphasized adult vaccine availability and accessibility in the country.

Unveiling the Uncertainties: Exploring the Utility of Herpes Zoster Vaccines.

Herpes zoster, commonly known as shingles, is a viral infection caused by the reactivation of the varicella-zoster virus (VZV). After primary infection with VZV, which causes chickenpox, the virus remains dormant in the sensory ganglia. However, it can reactivate later in life, leading to the development of shingles. Shingles typically presents as a painful, unilateral, and vesicular rash along the distribution of sensory nerves. The condition can be associated with significant morbidity, including severe pain, postherpetic neuralgia (PHN), and other complications. In this editorial, we will delve into the global and Indian burden of herpes zoster, explore its complications, highlight the importance of prevention, shed light on the Shingrix vaccine, discuss its composition, and present the research on safety and efficacy, including the ZOE-50 and ZOE-70 studies. Furthermore, we will review the recommendations on the Shingrix vaccine by leading global medical societies, including the esteemed Association of Physicians of India (API). How to cite this article: Vora A, Tiwaskar M. Unveiling the Uncertainties: Exploring the Utility of Herpes Zoster Vaccines. J Assoc Physicians India 2023;71(11):11-12.

Role of Bilastine in Allergic Rhinitis: A Narrative Review.

Allergic rhinitis (AR) is considered a trivial disease and is often self-treated with over-the-counter drugs and home remedies. However, AR is a contributing risk factor for asthma associated with complications, including chronic cough, eosinophilic esophagitis, and otitis media with effusion. In AR, inflammation is primarily mediated by histamines. Guidelines advise using second-generation oral H1 antihistamines as the primary treatment for AR. Second-generation H1 antihistamines strongly prefer the H1 receptor, limiting their ability to enter the central nervous system. Thus, they have minimal adverse effects. Among these H1 antihistamines, bilastine is highly specific for H1 receptors with a slight affinity for other receptors. It has a rapid and prolonged action, which reduces the need for frequent dosing and has better compliance. In the long term, bilastine is well-tolerated with minimal adverse effects. It is not associated with drug interactions, so dosage adjustment is unnecessary. Bilastine does not penetrate the brain and is nonsedating at 80 mg once daily. The low possibility of drug-drug interactions and pharmacokinetics of bilastine makes it suitable for elderly patients, even with compromised hepatic and renal function, without dose adjustment. This review comprehensively discusses the guidelines and the role of bilastine in treating AR. How to cite this article: Tiwaskar M, Vora A, Tewary K, et al. Role of Bilastine in Allergic Rhinitis: A Narrative Review. J Assoc Physicians India 2023;71(11):58-61.

Monkeypox: What do we know so far? A short narrative review of literature.

Monkeypox was a zoonotic infection, first detected in parts of northern Africa in the 1970s. Monkeypoxvirus, the causative agent of monkeypox, is a species of genus Orthopoxvirus and is closely related to long-eradicated smallpox caused by variola virus. Outbreaks in the West (in USA, UK, and Ireland) along with periodic re-emergence of the disease in parts of Africa have generated concern among global health bodies due to the existent deficiency of guidelines for management of the disease. Genetic variations and altered mechanisms favoring better survival of the virus have made early identification of the disease during screening difficult, particularly in resource-limited settings like rural areas of Africa. Through evidences gathered from experimental studies conducted after these outbreaks, the virus is known to be transmitted from several animal reservoirs along with human-to-human contact of blood, body fluids, or aerosol. Early diagnosis through immunoassays and polymerase chain reaction (PCR) tests, although not very specific, allows early treatment and subsequently better patient survival and recovery. Presence of lymphadenopathy along with fever, sore throat, and a vesiculopustular rash is diagnostic. The virus affects the gastrointestinal, hematological, ocular, and respiratory systems, in like manner producing afflictions of the specific system. Treatment, through experimental data, has been preferred to be symptomatic, with the aim to prevent superinfections. Antivirals like cidofovir and tecovirimat have been studied upon and used in clinical trials with favorable outcomes. Antiviral immunoglobulins have also been used with success in certain patients for postexposure prophylaxis.

Real-World Experience with Favipiravir for the Treatment of Mild-to-Moderate COVID-19 in India.

Background: Favipiravir, an RNA-dependent RNA polymerase inhibitor (RdRp), is a broad-spectrum oral antiviral agent approved in India under emergency use authorization, for the treatment of mild-to-moderate coronavirus disease (COVID-19). The present study was planned to evaluate the effectiveness and safety of favipiravir in real-world clinical practice. Materials and Methods: This was a multicentric, retrospective, single-arm study conducted across four centres in India, after obtaining permission from the independent ethics committee. Medical records were analysed to evaluate effectiveness and safety of patients who were prescribed favipiravir. Results: The medical records of a total of 360 patients met the inclusion criteria, with 358 of them available for the final analysis. Males made up 58.46% of the study population. The average age of enrolled patients was 51.80 ± 16.45 years. The most common symptoms were fever, cough, and myalgia-fatigue. The median time to clinical cure and fever relief was five and four days, respectively. The average length of stay in the hospital was six days. In total, 8% of the patients experienced adverse events. Hepatic enzyme elevation, diarrhoea, decreased appetite, headache, fatigue, and giddiness were the common symptoms. Conclusion: In our real-world study, favipiravir was found to have a clinical cure rate of more than 90% in mild-to-moderate COVID-19 patients. This supports the use of favipiravir in the treatment of COVID-19. Favipiravir was well tolerated, with only minimal side effects, which were transient in nature.

Community-acquired round Pneumonia in a 63-year-old Female.

Round pneumonia is a radiological manifestation of pulmonary lesion. This is found as spherical or oval-shaped radio-opacity on chest X-ray. Round pneumonia has been reported in literature uncommonly. Round pneumonia was first time reported in the radiology literature in 1954 (Wagner et al., 1998). It was first recognized in children. In 1973, Rose and Ward reviewed 21 cases of round pneumonia in children. Radiological findings resembled pulmonary and mediastinal masses. Since then, time and again, round pneumonia has been reported in children; but, this is also found rarely in adults. There are many causes of round pneumonia in adults, for example, infectious and noninfectious. It may mimic pulmonary neoplasms due to its radiological appearance. Hence, the usual diagnostic challenge of round pneumonia is to differentiate pneumonia from bronchogenic carcinoma. Here we present an interesting case of round pneumonia in an adult female.

The need for vaccination in adults with chronic (noncommunicable) diseases in India - lessons from around the world.

Worldwide, chronic diseases (noncommunicable diseases [NCDs]) cause 41 million (71%) deaths annually. They are the leading cause of mortality in India, contributing to 60% of total deaths each year. Individuals with these diseases are more susceptible to vaccine-preventable diseases (VPDs) and have an increased risk of associated disease severity and complications. This poses a substantial burden on healthcare systems and economies, exemplified by the COVID-19 pandemic. Vaccines are an effective strategy to combat these challenges; however, utilization rates are inadequate. With India running one of the world's largest COVID-19 vaccination programs, this presents an opportunity to improve vaccination coverage for all VPDs. Here we discuss the burden of VPDs in those with NCDs, the benefit of vaccinations, current challenges and possible strategies that may facilitate implementation and accessibility of vaccination programs. Effective vaccination will have a significant impact on the disease burden of both VPDs and NCDs and beyond.

What is already known on this topic?Annually, chronic or noncommunicable diseases (NCDs) cause >40 million deaths worldwide and 60% of all deaths in IndiaAdults with these diseases are more susceptible to vaccine-preventable diseases (VPDs); however, vaccine utilization is inadequate in this populationWhat is added by this report?We highlight the benefits of vaccination in adults with NCDs that extend beyond disease preventionWe discuss key challenges in implementing adult vaccination programs and provide practical solutionsWhat are the implications for public health practice?Raising awareness about the benefits of vaccinations, particularly for those with NCDs, and providing national guidelines with recommendations from medical societies, will increase vaccine acceptanceAdequate vaccine acceptance will reduce the VPD burden in this vulnerable population.

A Rare Cause of Breathlessness in a Patient on Hemodialysis.

Patients suffering from end stage renal disease (ESRD) often present to the emergency with breathlessness, mostly due to fluid overload. We report a rare case of recurrent unilateral massive pleural effusion in an ESRD patient on maintenance hemodialysis (MHD). The patient was on MHD thrice weekly for the last 2 years with right internal jugular vein (IJV) tunneled cuffed catheter (TCC). Chylothorax was identified as the cause of recurrent pleural effusion which was due to superior vena cava stenosis (SVCO). It was managed successfully by balloon venoplasty of SVC and anticoagulation. SVCO is a rare but a serious complication in patients on long term indwelling dialysis catheters. Physicians involved in the care of dialysis patients must be aware about complications of long term dialysis catheters like central vein stenosis. A strong suspicion of chylothorax should be reserved for a patient with recurrent unilateral pleural effusion and long term dialysis catheters.

Salmeterol-Fluticasone: The Role Revisited.

Apart from the individual diseases, some patients also show overlapping manifestations of asthma and COPD. Nevertheless, the diagnosis of COPD is often delayed due to inaccessibility to spirometry; the prevalence of the asthma COPD overlap phenotype is rather high given the exposure to biomass smoke. Furthermore, the rates of exacerbations are twice as high compared to the patients with either of the diseases. A treatment strategy that would reduce the risk of exacerbations would contribute immensely to the management of such patients. Evidence of eosinophilia (marker of inflammation) in patients with asthma, asthma COPD overlap phenotype or COPD alone should prompt treatment with a combination of inhaled corticosteroids (ICS)/ long-acting ß-agonists (LABA); several studies have shown improvement in the airflow limitation and reduction in the rate of exacerbations with salmeterol-fluticasone combination (SFC). Considering the association of COPD and cardiovascular diseases (CVD), it is critical to determine the cardiovascular safety of the LABA in such patients. Salmeterol is a highly selective partial b-2 agonist; the TORCH study and the studies comparing formoterol and salmeterol infer that there is no increased risk of new cardiovascular adverse events either with Salmeterol or SFC. Furthermore, the combination may provide certain degree of cardio-protection. Since COPD per se increases the risk of CVD, the cardio-safety of salmeterol outweighs its onset of action. SFC has well substantiated benefits in patients with asthma, COPD and high-risk patients such as those with an overlap of COPD and asthma symptoms, patients with elevated eosinophils and pre-existing CVD. An advisory board was hence conducted, which discussed the role of combination of salmeterol and fluticasone (SFC) not only in asthma and COPD but also in asthma COPD overlap phenotype. Based on the panel's clinical experience and the expertise derived thereof, the propositions regarding the place of SFC therapy in patients with stable and uncontrolled asthma, asthma COPD overlap phenotype and COPD has been put forth.