Sanjay Sethi, MD: Aclidinium Bromide in COPD

Today at the CHEST 2019 Annual Meeting in New Orleans, investigators presented ASCENT-COPD data showing aclidinium bromide significantly benefits exacerbation risk reduction in patients with chronic obstructive pulmonary disease (COPD) and a risk of cardiovascular events.

The findings evidence what clinicians including Sanjay Sethi, MD, have already known: that bronchodilation is integral to exacerbation reduction—and exacerbation reduction is the key to proper COPD management.

In an interview with MD Magazine® while at CHEST, Sethi, professor of Medicine at the University of Buffalo, explained the long-term benefit of COPD bronchodilation, and newly understood safety of aclidinium bromide in this patient population.

MD Mag: How does aclidinium bromide benefit cardiovascular risk in patients with COPD?

Sethi: I think there are 2 aspects to it. One aspect is, it a safety signal. There was this concern raised in some of the earlier studies with these LAMA agents—is there a safety signal from them, in terms of cardiovascular side effects.

So that's been allayed now. Now, we had previously one large study bit with tiotropium, and now we have another large study with aclidinium, which is part of this new combination. Both are very well done studies, large studies which show in fact that the incidence of what we call major adverse cardiovascular events, or MACE events, was if anything lower while being on the medication. So, definitely not higher of course. That was an endpoint.

I don't want to say that they protect from cardiovascular events. But clearly the events were no higher, and numerically lower than placebo. I think that's one aspect of it.

The second aspect is that, if you are able to bronchodilate more, you're enhancing their oxygen delivery, you’re preventing deconditioning down the road—that all could also have benefits. If they're able to walk more, that’s going preserve their cardiovascular abilities.

This is speculation, but indirectly, I think keeping these patients optimally bronchodilated could actually lead to better outcomes—not just lung-wise but beyond that.

MD Mag: What is the benefit in aclidinium showing efficacy in patients without COPD exacerbation history?

Sethi: The bronchodilators are fundamental to the treatment of COPD. What's interesting is, yes we are very focused on exacerbations nowadays in COPD, but 60% or 70% of people with COPD don't have exacerbations, or really, infrequent exacerbations.

So in that population what you really want to treat is symptoms. And this is new, and that's what the bronchodilators do well enough. Plus, we've also come to realize that aclidinium bronchodilation, by whatever mechanisms, leads to a reduction in exacerbations too.

The trend now is to optimally bronchodilate—use 2 bronchodilators. And then if you have still have persistent exacerbations or frequent exacerbations, then bring in things like inhaled steroids. And then we have a couple of other choices.

So that's become a step-up approach, different from asthma. In asthma, we tend to kind of throw everything in there and then back off. In COPD, it's still a step-up, progressive approach with the bronchodilators being central and fundamental.