Constance Chace, MD, MPH

Background: The Global Initiative for Obstructive Lung Disease (GOLD) recommends triple therapy with inhaled corticosteroids, long-acting beta₂-adrenoceptor agonists (LABA), and long-acting muscarinic receptor antagonists (LAMA) for patients with severe COPD who have frequent exacerbations despite treatment with a LABA and LAMA. Triple therapy has been shown to improve forced expiratory volume in 1 second (FEV1), but its effect on preventing exacerbations has not been well documented in previous meta-analyses.

Study design: Meta-analysis.

Setting: Studies published on PubMed, Embase, Cochrane Library website, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases.

Synopsis: 21 randomized, controlled trials of triple therapy in stable cases of moderate to very severe COPD were included in this meta-analysis. Triple therapy was associated with a significantly greater reduction in the rate of COPD exacerbations, compared with dual therapy of LAMA and LABA (rate ratio, 0.78; 95% confidence interval, 0.70-0.88), inhaled corticosteroid and LABA (rate ratio, 0.77; 95% CI, 0.66-0.91), or LAMA monotherapy (rate ratio, 0.71; 95% CI, 0.60-0.85). Triple therapy was also associated with greater improvement in FEV1.

There was a significantly higher incidence of pneumonia in patients using triple therapy, compared with those using dual therapy (LAMA and LABA), and there also was a trend toward increased pneumonia incidence with triple therapy, compared with LAMA monotherapy. Triple therapy was not shown to improve survival; however, most trials lasted less than 6 months, which limits their analysis of survival outcomes.

Bottom line: In patients with advanced COPD, triple therapy is associated with lower rates of COPD exacerbations and improved lung function, compared with dual therapy or monotherapy.

Citation: Zheng Y et al. Triple therapy in the management of chronic obstructive pulmonary disease: Systemic review and meta-analysis. BMJ. 2018;363:k4388.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: The Global Initiative for Obstructive Lung Disease (GOLD) recommends triple therapy with inhaled corticosteroids, long-acting beta₂-adrenoceptor agonists (LABA), and long-acting muscarinic receptor antagonists (LAMA) for patients with severe COPD who have frequent exacerbations despite treatment with a LABA and LAMA. Triple therapy has been shown to improve forced expiratory volume in 1 second (FEV1), but its effect on preventing exacerbations has not been well documented in previous meta-analyses.

Study design: Meta-analysis.

Setting: Studies published on PubMed, Embase, Cochrane Library website, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases.

Synopsis: 21 randomized, controlled trials of triple therapy in stable cases of moderate to very severe COPD were included in this meta-analysis. Triple therapy was associated with a significantly greater reduction in the rate of COPD exacerbations, compared with dual therapy of LAMA and LABA (rate ratio, 0.78; 95% confidence interval, 0.70-0.88), inhaled corticosteroid and LABA (rate ratio, 0.77; 95% CI, 0.66-0.91), or LAMA monotherapy (rate ratio, 0.71; 95% CI, 0.60-0.85). Triple therapy was also associated with greater improvement in FEV1.

There was a significantly higher incidence of pneumonia in patients using triple therapy, compared with those using dual therapy (LAMA and LABA), and there also was a trend toward increased pneumonia incidence with triple therapy, compared with LAMA monotherapy. Triple therapy was not shown to improve survival; however, most trials lasted less than 6 months, which limits their analysis of survival outcomes.

Bottom line: In patients with advanced COPD, triple therapy is associated with lower rates of COPD exacerbations and improved lung function, compared with dual therapy or monotherapy.

Citation: Zheng Y et al. Triple therapy in the management of chronic obstructive pulmonary disease: Systemic review and meta-analysis. BMJ. 2018;363:k4388.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: The Global Initiative for Obstructive Lung Disease (GOLD) recommends triple therapy with inhaled corticosteroids, long-acting beta₂-adrenoceptor agonists (LABA), and long-acting muscarinic receptor antagonists (LAMA) for patients with severe COPD who have frequent exacerbations despite treatment with a LABA and LAMA. Triple therapy has been shown to improve forced expiratory volume in 1 second (FEV1), but its effect on preventing exacerbations has not been well documented in previous meta-analyses.

Study design: Meta-analysis.

Setting: Studies published on PubMed, Embase, Cochrane Library website, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases.

Synopsis: 21 randomized, controlled trials of triple therapy in stable cases of moderate to very severe COPD were included in this meta-analysis. Triple therapy was associated with a significantly greater reduction in the rate of COPD exacerbations, compared with dual therapy of LAMA and LABA (rate ratio, 0.78; 95% confidence interval, 0.70-0.88), inhaled corticosteroid and LABA (rate ratio, 0.77; 95% CI, 0.66-0.91), or LAMA monotherapy (rate ratio, 0.71; 95% CI, 0.60-0.85). Triple therapy was also associated with greater improvement in FEV1.

There was a significantly higher incidence of pneumonia in patients using triple therapy, compared with those using dual therapy (LAMA and LABA), and there also was a trend toward increased pneumonia incidence with triple therapy, compared with LAMA monotherapy. Triple therapy was not shown to improve survival; however, most trials lasted less than 6 months, which limits their analysis of survival outcomes.

Bottom line: In patients with advanced COPD, triple therapy is associated with lower rates of COPD exacerbations and improved lung function, compared with dual therapy or monotherapy.

Citation: Zheng Y et al. Triple therapy in the management of chronic obstructive pulmonary disease: Systemic review and meta-analysis. BMJ. 2018;363:k4388.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: Acute hospitalization has been associated with functional and cognitive decline, particularly in elderly adults. This decline is associated with increased morbidity and mortality.

Study design: Single-center, single-blind, randomized clinical trial.

Setting: Acute care unit in a tertiary public hospital in Navarra, Spain.

Synopsis: 370 patients aged 75 years or older who were hospitalized in an acute care unit received either individualized moderate intensity exercise regimens (focusing on resistance, balance, and walking) or standard hospital care (with physical rehabilitation as appropriate). Patients who received standard care had a decrease in functional capacity at discharge when compared with their baseline function (mean change of –5.0 points on the Barthel Index of Independence; 95% confidence interval, –6.8 to –3.2 points), while those who received the exercise intervention had no functional decline from baseline on discharge (mean change of 1.9 points; 95% CI, 0.2-3.7 points).

Patients who received the exercise intervention had significantly higher scores on functional and cognitive assessments at discharge, compared with patients who received standard hospital care alone. Specifically, the study demonstrated a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the Short Physical Performance Battery, 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index, and 1.8 points (95% CI, 1.3-2.3 points) on a cognitive assessment, compared with those who received standard hospital care.

Bottom line: An individualized, multicomponent exercise intervention can help reverse functional and cognitive decline associated with acute hospitalization in elderly patients.

Citation: Martinez-Velilla N et al. Effect of exercise intervention on functional decline in very elderly adults during acute hospitalization. JAMA Intern Med. 2019;179(1):28-36.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: Acute hospitalization has been associated with functional and cognitive decline, particularly in elderly adults. This decline is associated with increased morbidity and mortality.

Study design: Single-center, single-blind, randomized clinical trial.

Setting: Acute care unit in a tertiary public hospital in Navarra, Spain.

Synopsis: 370 patients aged 75 years or older who were hospitalized in an acute care unit received either individualized moderate intensity exercise regimens (focusing on resistance, balance, and walking) or standard hospital care (with physical rehabilitation as appropriate). Patients who received standard care had a decrease in functional capacity at discharge when compared with their baseline function (mean change of –5.0 points on the Barthel Index of Independence; 95% confidence interval, –6.8 to –3.2 points), while those who received the exercise intervention had no functional decline from baseline on discharge (mean change of 1.9 points; 95% CI, 0.2-3.7 points).

Patients who received the exercise intervention had significantly higher scores on functional and cognitive assessments at discharge, compared with patients who received standard hospital care alone. Specifically, the study demonstrated a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the Short Physical Performance Battery, 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index, and 1.8 points (95% CI, 1.3-2.3 points) on a cognitive assessment, compared with those who received standard hospital care.

Bottom line: An individualized, multicomponent exercise intervention can help reverse functional and cognitive decline associated with acute hospitalization in elderly patients.

Citation: Martinez-Velilla N et al. Effect of exercise intervention on functional decline in very elderly adults during acute hospitalization. JAMA Intern Med. 2019;179(1):28-36.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: Acute hospitalization has been associated with functional and cognitive decline, particularly in elderly adults. This decline is associated with increased morbidity and mortality.

Study design: Single-center, single-blind, randomized clinical trial.

Setting: Acute care unit in a tertiary public hospital in Navarra, Spain.

Synopsis: 370 patients aged 75 years or older who were hospitalized in an acute care unit received either individualized moderate intensity exercise regimens (focusing on resistance, balance, and walking) or standard hospital care (with physical rehabilitation as appropriate). Patients who received standard care had a decrease in functional capacity at discharge when compared with their baseline function (mean change of –5.0 points on the Barthel Index of Independence; 95% confidence interval, –6.8 to –3.2 points), while those who received the exercise intervention had no functional decline from baseline on discharge (mean change of 1.9 points; 95% CI, 0.2-3.7 points).

Patients who received the exercise intervention had significantly higher scores on functional and cognitive assessments at discharge, compared with patients who received standard hospital care alone. Specifically, the study demonstrated a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the Short Physical Performance Battery, 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index, and 1.8 points (95% CI, 1.3-2.3 points) on a cognitive assessment, compared with those who received standard hospital care.

Bottom line: An individualized, multicomponent exercise intervention can help reverse functional and cognitive decline associated with acute hospitalization in elderly patients.

Citation: Martinez-Velilla N et al. Effect of exercise intervention on functional decline in very elderly adults during acute hospitalization. JAMA Intern Med. 2019;179(1):28-36.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.