M. Hashim Khan

Respirologist @UHN | Asthma, Airways diseases & Smoking | Global Health, Data Science, Advocacy & Policy | Son-Husband-Father | .ca .pk | Views my own

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc pls remind me, how did they track adherence to baseline COPD inhaler meds? Did they do pharmacy or inhaler checks? pulmonary rehab cointervention? managed by GP vs specialist? #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc 1) little/no efforts at environmental control (e.g. smoking cessation), 2) critical errors with inhaler technique/efforts at addressing adherence barriers. One would argue that those "less exciting" interventions give way more value.

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc for my patients with COPD and sign eosinophilia and recurrent exacerbations, I was treating them with higher dose ICS with some benefit. Am interested in the significant costs to the health system with many pts who will be put on Dupi vs costs of exac #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc agreed. the increased risk of PNA is well recognized, likely higher with higher dose ICS (although pts already on it). I've also seen pts though put on biologics/chronic pred as exciting new kids on the block and when I've seen them in post-discharge clinic the main issues are:

[M. Hashim Khan @MHashimKhanMD]

@donsin4 @respandsleepjc how does it correlate with say, transbronchial biopsies, instead of BAL? Less ideal/safe, of course.

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc would expect perhaps similar/better exac risk reduction with upstream-target biologics as well eg. tezepilumab. #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc exciting new study out showing finally a biologic option for patients with COPD and eosinophilia and recurrent exac, with risk reduction of 30%. Benefit likely because exac/airway inflamm not purely eos-driven, hence why mixed results with Nucala/Fasenra #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc arguably more clinically meaningful to us, and perhaps to patients also (although I'm sure they'd like less symptoms also). Seems from this study the exacerbation event rate was actually quite low - likely due to the short study duration/follow-up period.

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc A number of explanations for them not meeting primary outcome of SGRQ change which is a pretty "low bar", but best for symptoms: weaker dose (even if BID) than what is available in Canada, >1/3 of those randomized excluded from analysis for notable reasons- #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc finally, although MCID for SGRQ is 4, imp to remember that is for Rx being "minimally efficacious" - differences of 8 or 12 needed for "moderately" or "very" efficacious Rx.
One would expect this patient group to desire something > minimally efficacious #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc hmm i don't know. maybe not, but if even in short-term can't see benefit in improving symptoms, doubt there is much justification for doing a longer study, waiting for things to improve or change (when they likely won't)

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc Did they justify their sample size calc? May just not have been powered enough to detect difference. Hopefully --> less inappropriately Rxed long-acting bronchodilators. Credit for publishing this "negative" trial - which remember, can still be informative. #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc I would also be interested in knowing specifically whether they documented DLCO or radiographic emphysema - would be useful to know if these patients benefit (if at all) with bronchodilator Rx (wouldn't be surprised if they don't, but useful if they do). #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc I would be more interested in something where Rx was ICS-bronchodilator (targeting airway inflammation from ongoing smoking which likely is responsible for symptoms/temporary large/small airways obstruction) -- that study may show differences in outcomes #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc did they exclude SABA? (arguably most prescribed Rx for this group - and taken PRN vs. "taken as maintenance". Despite study limitations, not surprised about findings showing no difference in symptoms between groups. #rsjc

[M. Hashim Khan @MHashimKhanMD]

10% withdrawal rate, and issues that highlight study validity issues - ineligible after randomization?? wrong kits?? adherence issues - fine, an issue in many inhaler Rx trials but can be mitigated/tracked

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc interesting study that made it to NEJM. Maybe it's just me, but I typically wasn't prescribing bronchodilators to folks who are smokers (aka "smokers cough") and don't have airways obstruction (even if had symptoms) - just wasn't intuitive to me #rsjc

[M. Hashim Khan @MHashimKhanMD]

@respandsleepjc here :) #rsjc

[M. Hashim Khan @MHashimKhanMD]

@ASPphysician Sounds like a perfect setup for the next @respandsleepjc, @drstanbrook and @thelungdr (if the studies haven't been picked yet)!

[M. Hashim Khan @MHashimKhanMD]

That is, if we are honest about valuing all lives as equal to our own. We are the Rosedale of the world and the longer this pandemic goes on, the more variants we'll have to contend with.

Politics and greed have gotten us nowhere. Humanity is sacred and history will judge us.

[M. Hashim Khan @MHashimKhanMD]

Unpopular opinion but I'll say it again.

If we're advocating for the fire to be doused in hotspots across #Peel and #Toronto, then we should be screaming at the top of our lungs to help #Indians and all hotspot countries however we can with their pandemic responses as well.

[M. Hashim Khan @MHashimKhanMD]

💯 Overcoming this and future pandemics in an increasingly globalized world requires a desire & will to equitably distribute all effective measures – testing kits, PPE, treatments or vaccines – not just to those disproportionately affected within our borders, but beyond as well.