E-cigarettes in patients with COPD: current perspectives.

Conventional cigarette smoking is known to result in significant COPD morbidity and mortality. Strategies to reduce and/or stop smoking in this highly vulnerable patient group are key public health priorities to reduce COPD morbidity and mortality. Unfortunately, smoking cessation efforts in patients with COPD are poor and there is a compelling need for more efficient approaches to cessation for patients with COPD. Electronic cigarettes (ECs) are devices that use batteries to vaporize nicotine. They may facilitate quit attempts and cessation in many smokers. Although they are not risk free, ECs are much less harmful than tobacco smoking. Hence, the use of ECs in vulnerable groups and in patients with challenges to abstain or multiple relapses to this habit may be promising. To date, little is known about health consequences of EC use among COPD smokers and whether their regular use has any effects on subjective and objective COPD outcomes. In the current review, we discuss the current perspectives and literature on the role of ECs in abstaining from conventional smoking and the effects of ECs on the respiratory tract in patients with COPD.

Novel anti-cholinergics in COPD.

Anti-cholinergics have been considered the first-choice bronchodilator therapy in the routine management of stable COPD. Muscarinic cholinergic receptors are expressed on most cell types and mediate cellular signalling via the natural ligand, acetylcholine. Antagonising cholinergic receptors may not only result in bronchodilation, but also have associated localised activity. Until recently the licensed anti-cholinergics were limited to ipatropium bromide, oxitropium bromide and tiotropium bromide; the latter being the only once-daily anti-cholinergic. With the patents expired or due to expire shortly several companies have reinitiated efforts to develop safer, long-acting agents potentially improving concordance and pharmaceutical marketing opportunities. The present article reviews a number of novel anti-cholinergics that have been recently licensed and those undergoing development, some in innovative delivery devices.

Role of long term antibiotics in chronic respiratory diseases.

Antibiotics are commonly used in the management of respiratory disorders such as cystic fibrosis (CF), non-CF bronchiectasis, asthma and COPD. In those conditions long-term antibiotics can be delivered as nebulised aerosols or administered orally. In CF, nebulised colomycin or tobramycin improve lung function, reduce number of exacerbations and improve quality of life (QoL). Oral antibiotics, such as macrolides, have acquired wide use not only as anti-microbial agents but also due to their anti-inflammatory and pro-kinetic properties. In CF, macrolides such as azithromycin have been shown to improve the lung function and reduce frequency of infective exacerbations. Similarly macrolides have been shown to have some benefits in COPD including reduction in a number of exacerbations. In asthma, macrolides have been reported to improve some subjective parameters, bronchial hyperresponsiveness and airway inflammation; however have no benefits on lung function or overall asthma control. Macrolides have also been used with beneficial effects in less common disorders such as diffuse panbronchiolitis or post-transplant bronchiolitis obliterans syndrome. In this review we describe our current knowledge the use of long-term antibiotics in conditions such as CF, non-CF bronchiectasis, asthma and COPD together with up-to-date clinical and scientific evidence to support our understanding of the use of antibiotics in those conditions.

The role of a soluble TNFalpha receptor fusion protein (etanercept) in corticosteroid refractory asthma: a double blind, randomised, placebo controlled trial.

AIM: Tumour necrosis factor alpha (TNFalpha) is a cytokine recognised as a therapeutic target in chronic inflammatory diseases. METHODS: A randomised, double blind, placebo controlled parallel group trial is reported of etanercept (an IgG1-TNF p75 receptor fusion protein), administered once weekly for 12 weeks in 39 patients with severe corticosteroid refractory asthma. Efficacy was measured by change from the pretreatment baseline in Asthma Related Quality of Life (AQLQ) and Asthma Control (ACQ) Questionnaire scores (the primary endpoints), lung function, peak expiratory flow (PEF) and bronchial hyperresponsiveness (BHR). Sputum and serum inflammatory cells and cytokines, serum albumin and C reactive protein (CRP) as biomarkers of inflammation were also assessed. RESULTS: There was a small but significant difference in reduction of ACQ scores between treatment and placebo (-1.11 (95% CI -1.56 to -0.75) and -0.52 (95% CI -0.97 to -0.07), respectively, p = 0.037). There was no significant difference in improvements in AQLQ scores, lung function, PEF, BHR or exacerbation rates between the groups. Minor adverse events, including injection site pain and skin rashes, were more frequent with etanercept. There was a significant reduction in sputum macrophages and CRP, and increases in serum TNFalpha and albumin following treatment, but not in other laboratory parameters. CONCLUSION: Etanercept therapy over 12 weeks demonstrated only a small but significant improvement in asthma control and systemic inflammation, as measured by serum albumin and CRP. Larger randomised, placebo controlled trials are required to clarify the role of TNFalpha antagonism in subjects with severe refractory asthma.