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The development of biomarker-driven targeted therapy has resulted in substantial benefits for patients with non–small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations, and rearrangements involving the anaplastic lymphoma kinase (ALK) gene or the ROS1 gene. For patients with EGFR-mutant NSCLC EGFR tyrosine kinase inhibitors (eg, gefitinib, erlotinib, and afatinib) have a superior objective response rate and progression-free survival compared with chemotherapy in the first-line setting. For patients who have disease progression on EGFR tyrosine kinase inhibitor and with NSCLC with an EGFR T790M mutation osimertinib has demonstrated a superior response rate and progression-free survival compared with chemotherapy in the second-line setting.4 For patients with ALK rearrangements ALK tyrosine kinase inhibitors (eg, crizotinib, ceritinib) have a superior response rate and progression-free survival compared with chemotherapy in the first-line setting, and for patients who experience disease progression, ceritinib and alectinib have demonstrated clinically relevant response rates and progression-free survival..For patients with ROS1 rearrangements, targeted therapy, is associated with a higher response rate and longer progression-free survival than has been observed with chemotherapy. These molecular alterations are more common in NSCLC with adenocarcinoma histology and in the minority of patients with a light smoking or never smoking history. The success of these targeted therapies in molecularly defined subsets of NSCLC made the development of targeted therapies and identification of predictive biomarkers a focus of thoracic oncology research. Routine molecular testing is now the standard of care for patients with NSCLC with adenocarcinoma histology
Practical Recommendations for COPD: Evidence-Based Care The treatment of patients with chronic obstructive pulmonary disease (COPD) depends on symptoms and history of exacerbation. These elements define the treatment strategies within the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines' ABCD assessment tool • Although not taken into account in the ABCD tool, spirometry remains important for the diagnosis and assessment of airflow limitation. Bronchodilators are first-line treatment, either as a single or dual bronchodilator treatment. • The recently available combination of a long-acting beta agonist (LABA) and a long-acting muscarinic receptor antagonist (LAMA) into a single inhaler has demonstrated improvement in lung function, either in combination or with monotherapy. In the SPARK study evaluating indacaterol/glycopyrrolate vs glycopyrronium and tiotropium (LABA/LAMA vs LAMA alone) for the prevention of exacerbation in patients with COPD, the combination therapy was superior to a single bronchodilator as measured by the reduction of exacerbations. • LABA/LAMA was also shown to be superior in the ILLUMINATE study, which compared the patient-reported outcomes and the transition dyspnea index (TDI) for patients on LABA/LAMA with patients on LABA/ICS (inhaled corticosteroid). Data from multiple studies show that ICS-containing regimens can also effectively reduce exacerbation rates. Data from post-hoc analyses of clinical trials suggest that patients with high levels of blood eosinophils may respond better to ICS therapy, whereas patients with very low levels of eosinophils may not respond. ICS therapy is associated with serious side effects, such as pneumonia. In the WISDOM trial, patients who discontinued ICS experienced approximately 40 mL in forced expiratory volume over 1 second (FEV1), indicating that ICS should be withdrawn very carefully in some patients. As exacerbations are more frequent and often more severe in winter months, it is recommended to not withdraw steroids during that period Current evidence suggests that the combination of LABA/LAMA with ICS into a single inhaler will improve lung function, exacerbations, and symptoms Other treatment options besides triple therapy exist for patients who still experience exacerbations after LABA/LAMA treatment. • Roflumilast may be considered in patients with chronic bronchitis. • The use of long-term macrolides is possible in a particular profile subset of patients who have frequent exacerbations with bronchiectasis, bronchial colonization, and frequent bacterial infections.
Comprehensive and Individualized Patient Care in Idiopathic Pulmonary Fibrosis: Refining Approaches to Diagnosis, Prognosis, and Treatment Implement multidisciplinary clinical and imaging approaches to achieve more timely and accurate diagnosis of IPF • Develop IPF treatment strategies based on key guideline recommendations and examine the supporting clinical trial data • Describe key elements of an individualized approach to IPF treatment that involves shared decision-making Standard immunosuppressive therapy is no longer indicated, whereas pirfenidone, nintedanib, and antacid therapy are all conditionally recommended for use. Individualizing treatment is important in light of potential improved adherence to both drug therapy and health behaviors. An early referral to an interstitial lung disease center offers the advantages of comprehensive diagnostic and disease-management expertise, potential enrollment in a clinical trial, and evaluation for transplantation.
Obstructive sleep apnea (OSA) is a heterogeneous disorder. If left untreated, OSA has major health, safety and economic consequences. In addition to varying levels of impairment in pharyngeal anatomy (narrow/collapsible airway), non-anatomical ‘phenotypic traits’ are also important contributors to OSA for most patients. However, the majority of existing therapies only target the anatomical cause (e.g. continuous positive airway pressure [CPAP], oral appliances, weight loss, positional therapy, and upper airway surgery). These are typically administered as monotherapy according to a trial and error management approach in which the majority of patients are first prescribed CPAP. Despite its high effectiveness, CPAP adherence remains unacceptably low and second-line therapies have variable and unpredictable efficacies. Recent advances in knowledge of the multiple causes of OSA using respiratory phenotyping techniques have identified new targets or ‘treatable traits’ to direct therapy. Identification of the traits and development of therapies that selectively target one or more of the treatable traits has the potential to personalize the management of this chronic health condition to optimize patient outcomes according to precision medicine principles.
Oxygen therapy for interstitial lung disease: a systematic review Eur Respir Rev 2017; 26: 160080 This systematic review showed no effects of oxygen therapy on dyspnoea during exercise in ILD, although exercise capacity was increased.
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