Fixed dose triple therapy in a pMDI for patients with moderate to very severe COPD
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An inexplicable abnormal result highlights the role of a little known test, cystatin C, when assessing kidney function in those at the extremes of muscle mass.
Dr Penny Figtree GP, Port Macquarie, NSW( top left). Dr Liz Fraser GP, Canberra, ACT( top right). Professor Karen Dwyer Nephrologist, Royal Melbourne Hospital; professor of medicine, University of Melbourne, Victoria( bottom left). Dr Alok Gupta Nephrologist, Toowoomba, Queensland( bottom right).
SIMON, aged 56, takes pride in his good health. He works long hours as a bank manager, but also prioritises maintaining a healthy lifestyle and regular exercise. He is well, a non-smoker, and takes no medications. He eats whole foods, mostly low carb with plenty of protein. He lifts weights at the local gym three times a week.
When Simon books in with his GP for a routine checkup, he says he feels great. The GP notes that he has coeliac disease, and that there is no family history of diabetes, or cardiovascular or renal disease.
On examination, Simon appears to be a healthy middle-aged male. His weight is 74kg, height 178cm, waist circumference 85cm and BMI 23.4kg / m 2. His BP is 115 / 70mmHg and urine analysis is
unremarkable. The GP orders routine blood tests.
Investigations
Simon’ s results show HbA1c is in healthy range at 5 %( normal: 3.5-6). His CRP is < 0.4mg / L( normal: < 5.0). There is no albuminuria.
However, his creatinine is raised at 130μmol / L( normal for age: 60-110), and based on this his estimated GFR using the CKD-EPI formula is low at 54mL / min / 1.73m 2( lab normal range: > 59). The UEC is repeated on a further two occasions, confirming these findings. The GP diagnoses Simon with CKD 3a.
Progress
When Simon receives the results, he is shocked and distressed to learn that he has chronic kidney disease. Simon double checks with his parents and siblings regarding their family history and confirms there is none of kidney disease.
The GP organises a renal ultrasound which is normal. Simon is referred to a dietitian who recommends a low sodium, low protein diet.
A few months later Simon represents to the GP to discuss a conversation he had with another doctor, Adam, who also attends his gym. A few years ago Adam had been told he
had chronic kidney disease, due to his creatinine-based eGFR of 39mL / min / 1.73m 2.
Adam had even been advised at the time that he needed a kidney biopsy. But Adam was aware that creatinine-based eGFR may
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Fixed dose triple therapy in a pMDI for patients with moderate to very severe COPD
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INDICATION: BREZTRI AEROSPHERE ® is indicated as a maintenance treatment to prevent exacerbations and relieve symptoms in adults with moderate, severe, or very severe COPD who require treatment with a combination of ICS, LABA, and LAMA. 1 BREZTRI AEROSPHERE ® is not indicated for the initiation of therapy in COPD. 1 SAFETY: In ETHOS, adverse events that occurred in ≥3 % of patients overall for BREZTRI ® and GLY / FORM were nasopharyngitis, COPD, upper respiratory tract infection, pneumonia and bronchitis. 2 The incidence of confirmed pneumonia was 4.2 % with BREZTRI ® and 2.3 % with GLY / FORM. 1, 2 Please review Product Information for information on other Precautions and Adverse Effects.
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COPD = chronic obstructive pulmonary disease; FORM = formoterol; GLY = glycopyrronium; ICS = inhaled corticosteroid; LABA = long-acting beta 2 agonist; LAMA = long-acting muscarinic antagonist; pMDI = pressurised Metered Dose Inhaler. References: 1. BREZTRI AEROSPHERE ® Approved Product Information. 2. Rabe F et al. N Engl J Med. 2020; 383( 1): 35 – 48.
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