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Current concepts in targeting chronic obstructive pulmonary disease
pharmacotherapy: making progress towards personalised management
#MMPMID25943943
Woodruff PG
; Agusti A
; Roche N
; Singh D
; Martinez FJ
Lancet
2015[May]; 385
(9979
): 1789-1798
PMID25943943
show ga
Chronic obstructive pulmonary disease (COPD) is a common, complex, and
heterogeneous disorder that is responsible for substantial and growing morbidity,
mortality, and health-care expense worldwide. Of imperative importance to
decipher the complexity of COPD is to identify groups of patients with similar
clinical characteristics, prognosis, or therapeutic needs, the so-called clinical
phenotypes. This strategy is logical for research but might be of little clinical
value because clinical phenotypes can overlap in the same patient and the same
clinical phenotype could result from different biological mechanisms. With the
goal to match assessment with treatment choices, the latest iteration of
guidelines from the Global Initiative for Chronic Obstructive Lung Disease
reorganised treatment objectives into two categories: to improve symptoms (ie,
dyspnoea and health status) and to decrease future risk (as predicted by forced
expiratory volume in 1 s level and exacerbations history). This change thus moves
treatment closer to individualised medicine with available bronchodilators and
anti-inflammatory drugs. Yet, future treatment options are likely to include
targeting endotypes that represent subtypes of patients defined by a distinct
pathophysiological mechanism. Specific biomarkers of these endotypes would be
particularly useful in clinical practice, especially in patients in which
clinical phenotype alone is insufficient to identify the underlying endotype. A
few series of potential COPD endotypes and biomarkers have been suggested.
Empirical knowledge will be gained from proof-of-concept trials in COPD with
emerging drugs that target specific inflammatory pathways. In every instance,
specific endotype and biomarker efforts will probably be needed for the success
of these trials, because the pathways are likely to be operative in only a subset
of patients. Network analysis of human diseases offers the possibility to improve
understanding of disease pathobiological complexity and to help with the
development of new treatment alternatives and, importantly, a reclassification of
complex diseases. All these developments should pave the way towards personalised
treatment of patients with COPD in the clinic.
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