Therapy in Bronchiectasis: Successes, Failures, and a Call for a More Precise Approach
Across trials, macrolides reduced bronchiectasis flare-ups more than dipeptidyl peptidase-1 inhibitors, and lung function gains were small.
*Editorial commentary; Level 5 (OCEBM).
*Editorial commentary; Level 5 (OCEBM).
Citation
Jia S. Therapy in Bronchiectasis: Successes, Failures, and a Call for a More Precise Approach. Chest. 2026;169(6):1427-1429. doi:10.1016/j.chest.2026.02.009
Background
Bronchiectasis has many causes and patient subtypes, so one “best” antiinflammatory treatment is unlikely to fit everyone. This editorial discusses a large comparison of antiinflammatory treatments and argues for more precise matching of therapy to patient features.
Patients
Adults with non–cystic fibrosis bronchiectasis; many trials focused on people with frequent flare-ups (about 1–3 in the prior year). Cystic fibrosis was excluded.
Intervention
Antiinflammatory therapies, especially macrolide antibiotics and dipeptidyl peptidase-1 inhibitors.
Control
Placebo or usual care (varied by trial).
Outcome
Flare-up frequency; change in forced expiratory volume in 1 second (mL).
Follow-up Period
Varied by trial (often 6–12 months).
Results
| Therapy | Flare-up frequency (rate ratio, 95% CI) | Lung function change (mL, 95% CI) |
|---|---|---|
| Macrolides | 0.44 (0.35 to 0.56) | 104.3 (25.4 to 183.2) |
| Dipeptidyl peptidase-1 inhibitors | 0.73 (0.60 to 0.88) | 24.3 (2.6 to 46.0) |
Limitations
This is an editorial summarizing other studies, not a new trial. Many included trials mainly enrolled patients with frequent flare-ups, so results may not apply to people with few flare-ups but high daily symptoms or fast lung decline. The lung function improvement with dipeptidyl peptidase-1 inhibitors was statistically positive but likely too small to matter to most patients.
Funding
Supported by the National Heart, Lung, and Blood Institute (K23).
Clinical Application
For adults with frequent bronchiectasis flare-ups, consider long-term macrolides first when appropriate; dipeptidyl peptidase-1 inhibitors may help modestly. Applicability beyond frequent flare-ups is uncertain.
Discussion
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In this network meta-analysis of antiinflammatory therapies for non–CF bronchiectasis, macrolides reduced pulmonary exacerbation frequency (rate ratio 0.44; 95% CI 0.35–0.56) more than DPP1 inhibitors (0.73; 0.60–0.88). Given indirect comparisons and disease heterogeneity, is this evidence strong enough to change your first-line chronic therapy choices? The paper reports that macrolides lowered pulmonary exacerbation frequency with a rate ratio of 0.44. Which interpretation is most accurate?