Symptoms alone could guide bronchiectasis treatment
A multinational study of more than 9,000 patients has found that symptoms alone can predict future exacerbations in bronchiectasis, potentially expanding treatment eligibility beyond current guideline recommendations.
The research, published in The Lancet Respiratory Medicine [link here], challenges existing guidelines that limit long-term macrolide therapy to patients experiencing three or more exacerbations annually.
Lead author Dr Oriol Sibila from Hospital Clinic, University of Barcelona, and colleagues analysed data from the EMBARC registry alongside three randomised controlled trials to demonstrate that symptom severity independently predicts exacerbation risk.
“Previous exacerbations and symptoms were identified as independent risk factors for future exacerbations,” the authors reported, noting each additional previous exacerbation increased risk by 11% and every 10-point decrease in quality-of-life scores increasing risk by 10%.
Similar exacerbation rates found
The study revealed that patients with no previous exacerbations but high symptom burdens experienced similar exacerbation rates to those with frequent exacerbations and average symptoms.
Notably, patients with three or more baseline exacerbations and average symptom scores showed a rate ratio of 1.58 for future exacerbations, whilst those with no previous exacerbations but high symptoms showed a rate ratio of 1.55.
Additionally, post-hoc analysis of three macrolide trials involving 341 participants demonstrated comparable treatment benefits between these patient groups, the researchers said. The number needed to treat to prevent exacerbations was 1.45 for patients with frequent exacerbations versus 1.43 for those with high symptoms but few previous exacerbations, they reported.
The EMBARC registry included patients from 27 countries, with the median age being 68 years and 61% female participants. Most patients were from North and Western Europe, including the UK, with Southern Europe, Central and Eastern Europe, and Asia also represented. The research team featured several Australian contributors, with researchers from Melbourne, Adelaide, and Brisbane participating alongside data from the Australia-New Zealand EMBRACE trial.
Current guidelines may need revision
The authors noted current European Respiratory Society and British Thoracic Society guidelines recommended prophylactic macrolides only for patients with three or more annual exacerbations, based on established evidence that this population faced increased mortality and future exacerbation risk.
However, the new findings suggested that patients with high symptom burdens but minimal exacerbation histories may derive similar benefits from preventive treatment, they said.
“Our results suggest that symptoms are an independent risk factor for future exacerbations in bronchiectasis,” the authors concluded. “Patients who are highly symptomatic derive a similar benefit from macrolide treatment as patients with a high baseline exacerbation frequency.”
They pointed out their findings built on smaller studies from Scottish and Chinese hospitals that demonstrated similar relationships between symptoms and exacerbation risk, but represented the largest multinational validation of the concept.
Source: Geir O’Rourke – the limbic