SIX-MONTH CHANGE IN FVC PREDICTS MORTALITY IN PATIENTS WITH UIP/NSIP

Patients with usual interstitial pneumonia (UIP) or nonspecific interstitial pneumonia (NSIP) generally have a poor prognosis, and predicting survival is often problematic. Recently, Flaherty et al reported that over a six-month period, change in forced vital capacity (FVC) was the strongest predictor of survival in these patients.

Results of pulmonary function testing and high-resolution computed tomography (HRCT) were monitored in 109 patients with UIP or NSIP. Median survival time was 5.81 years. A decrease in FVC over six months was the only variable that was found to independently correlate with increased mortality.

A decrease in FVC of more than 10% over six months occurred more often in the patients with UIP than in those with NSIP. In both groups, though, a decrease of this magnitude predicted an increased risk of death. Changes in other lung function parameters were not significant predictors of mortality.

Initially, an increase of more than 10% in ground-glass opacities on an HRCT scan was also associated with a higher risk of death. However, after adjustment for baseline values, HRCT changes were no longer a significant mortality indicator.

The investigators noted that the ability to use short-term changes in FVC allows clinicians to better determine prognosis and make decisions regarding therapy or lung transplantation.

Flaherty KR, Mumford JA, Murray S, et al. Prognostic implications of physiologic and radiographic changes in idiopathic interstitial pneumonia. Am J Respir Crit Care Med. 2003;168:543-548.

OMALIZUMAB EFFECTIVE FOR THE LONG-TERM CONTROL OF ALLERGIC ASTHMA

In a 28-week, randomized double-blind placebo-controlled trial, omalizumab reduced the frequency and severity of exacerbations in patients with severe allergic asthma, and it also allowed them to reduce their use of inhaled corticosteroids. After a 24-week extension of that study, Lanier et al concluded that omalizumab is effective for the long-term control of symptoms in severe allergic asthma.

Four hundred sixty patients entered the extension phase of the study, in which they continued to receive either subcutaneous omalizumab (minimum dosage was 0.016 mg/kg every four weeks) or placebo. In addition, the patients used the lowest effective dose of beclomethasone. The occurrence of asthma exacerbations, changes in forced expiratory volume in one second (FEV1), and use of beclomethasone or other inhaled corticosteroids were evaluated every four weeks.

The number of patients having at least one exacerbation was significantly reduced in the treatment group (78 versus 92 in the placebo group).

Patients who continued therapy with omalizumab were able to use inhaled corticosteroids significantly less often than those in the control group. Twenty-seven percent of the treatment group completed the extension phase without needing any inhaled corticosteroids, compared with 10% of the control group. Also, more patients in the treatment group were able to maintain a dose of beclomethasone below 50% of their baseline requirement.

There was also a significant difference in FEV1 in favor of the treatment group. At 48 weeks, the difference in FEV1 between the groups was 40 mL, and at 52 weeks, it was 52 mL.

Long-term therapy with omalizumab improved symptoms and allowed patients to reduce their use of inhaled corticosteroids.

Lanier BQ, Corren J, Lumry W, et al. Omalizumab is effective in long-term control of severe allergic asthma. Ann Allergy Asthma Immunol. 2003;91:154-159.

INHERITED THROMBOPHILIC FACTORS DO NOT PREDICT VTE RECURRENCE

Patients who suffer a first episode of venous thromboembolism (VTE) and then stop using anticoagulants face a risk of VTE recurrence at two years of 12% to 18%. To determine risk factors for recurrence, Baglin et al used patient information from a clinical database and found that inherited risk factors for thrombophilia do not correlate with disease recurrence and that unselected screening for these factors is not justified.

Starting in 1997, patients referred to the study hospital for anticoagulant therapy after a first VTE were included in the database. Clinical risk factors were recorded, and 570 patients were assigned to one of four groups: surgery-associated VTE (group A); pregnancy-associated VTE (group B); VTE with no identifiable risk factors (group C); and VTE linked to nonsurgical risk factors (group D). After anticoagulant treatment ended, patients were offered thrombophilic testing and followed up at six months, one year, and two years.

Median patient age was 67. After cessation of anticoagulant therapy, the cumulative recurrence rate was 11%. There was no recurrence in groups A or B, but 32 (17%) of the 193 patients in group C and 21 (8%) of the 279 in group D had a second VTE. There was no evidence of a difference in recurrence between patients with laboratory evidence of an inherited thrombophilic defect and those without.

This study demonstrated that patients with postoperative VTE have a very low rate of recurrence and that patients with unprecipitated VTE have an almost 20% cumulative recurrence rate within two years of stopping anticoagulants. In addition, the patients with nonsurgical triggers for thromboembolism had a significantly lower rate of recurrence than did those with unprecipitated VTE. In no case did testing for inherited thrombophilic defects help predict recurrence.

Baglin T, Luddington R, Brown K, Baglin C. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet. 2003;362:523-526.