Rococo study: a real-world evaluation of an over-the-counter medicine in acute cough (a multicentre, randomised, controlled study)

OBJECTIVES

To investigate the efficacy and safety of CS1002, an over-the-counter cough treatment containing diphenhydramine, ammonium chloride and levomenthol in a cocoa-based demulcent.

DESIGN

A multicentre, randomised, parallel group, controlled, single-blinded study in participants with acute upper respiratory tract infection-associated cough.

SETTING

4 general practitioner (GP) surgeries and 14 pharmacies in the UK.

PARTICIPANTS

Participants aged ≥18 years who self-referred to a GP or pharmacist with acute cough of <7 days' duration. Participant inclusion criterion was cough severity ≥60 mm on a 0-100 mm visual analogue scale (VAS). Exclusion criteria included current smokers or history of smoking within the past 12 months (including e-cigarettes). 163 participants were randomised to the study (mean participant age 38 years, 57% females).

INTERVENTIONS

Participants were randomised to CS1002 (Unicough) or simple linctus (SL), a widely used cough treatment, and treatment duration was 7 days or until resolution of cough.

MAIN OUTCOME MEASURES

The primary analysis was intention-to-treat (157 participants) and comprised cough severity assessed using a VAS after 3 days' treatment (prespecified primary end point at day 4). Cough frequency, sleep disruption, health status (Leicester Cough Questionnaire (LCQ-acute)) and cough resolution were also assessed.

RESULTS

At day 4 (primary end point), the adjusted mean difference (95% CI) in cough severity VAS between CS1002 and SL was -5.9 mm (-14.4 to 2.7), p=0.18. At the end of the study (day 7) the mean difference in cough severity VAS was -4.2 mm (-12.2 to 3.9), p=0.31. CS1002 was associated with a greater reduction in cough sleep disruption (mean difference -11.6 mm (-20.6 to 2.7), p=0.01) and cough frequency (mean difference -8.1 mm (-16.2 to 0.1), p=0.05) compared with SL. There was greater improvement in LCQ-acute quality of life scores with CS1002 compared with SL: mean difference (95% CI) 1.2 (0.05 to 2.36), p=0.04 after 5 days' treatment. More participants prematurely stopped treatment due to cough improvement in the CS1002 group (24.4%) compared with SL (10.7%; p=0.02). Adverse events (AEs) were comparable between CS1002 (20.5%) and SL (27.6%) and largely related to the study indication. 6 participants (7%) in the CS1002 group reduced the dose of medication due to drowsiness/tiredness, which subsequently resolved. These events were not reported by participants as AEs.

CONCLUSIONS

Although the primary end point was not achieved, CS1002 was associated with greater reductions in cough frequency, sleep disruption and improved health status compared with SL.

TRIAL REGISTRATION NUMBER

EudraCT number 2014-004255-31.

Safety, pharmacokinetics, and pharmacodynamics of avoralstat, an oral plasma kallikrein inhibitor: phase 1 study

BACKGROUND

Avoralstat is a potent small-molecule oral plasma kallikrein inhibitor under development for treatment of hereditary angioedema (HAE). This first-in-human study evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics of avoralstat.

METHODS

This double-blind, placebo-controlled, ascending-dose cohort trial evaluated avoralstat single doses of 50, 125, 250, 500, and 1000 mg and multiple doses up to 2400 mg daily (100, 200, 400, and 800 mg every 8 h [q8 h] up to 7 days).

RESULTS

Avoralstat (n = 71) was generally well tolerated with no signals for a safety concern; there were no serious adverse events (AEs) or discontinuations due to AEs, and compared to placebo (n = 18), no notable difference in AEs. Four moderate severity AEs were reported in two subjects; syncope after a single 250 mg dose (one subject) and abdominal pain, back pain, and eczema after multiple doses of 800 mg avoralstat (one subject). For multiple-dose cohorts, the incidence of gastrointestinal AEs was highest at the 2400 mg/day dose. Elimination of avoralstat was bi-exponential with a terminal half-life of 12-31 h. Inhibition of plasma kallikrein was observed at all doses, and the degree of inhibition was highly correlated with avoralstat concentrations (R = 0.93). Mean avoralstat concentrations at doses ≥400 mg q8 h met or exceeded plasma kallikrein EC₅₀ values throughout the dosing interval.

CONCLUSION

Avoralstat was well tolerated, and drug exposure was sufficient to meet target levels for inhibition of plasma kallikrein. Based on these results, the 400 mg q8 h dose was selected for further evaluation in patients with HAE.

Pseudohyperkalaemia: a rare complication of splenectomy

Pseudohyperkalaemia is an uncommon and frequently unrecognised biochemical abnormality. It occurs as a consequence of aggregation and lysis of platelets in vitro. As a result, potassium is released, which causes an elevated serum concentration. We present the case of a 21-year-old man with a traumatic splenic injury necessitating laparotomy and splenectomy. Following surgery he developed hyperkalaemia. Further investigations diagnosed pseudohyperkalaemia, one of the causes of which is thrombocytosis secondary to splenectomy.

A Possible Relationship Between Toxicity and Carcinogenicity

Carcinogenic response is compared to noncarcinogenic toxicity in that group of chemicals tested by the National Cancer Institute (NCI) and National Toxicology Program (NTP) between 1976 and 1982 and reported in the Carcinogenesis Technical Report Series. A positive finding of carcinogenicity in the bioassay is correlated with the degree of noncarcinogenic chronic toxicity of the dose applied. Comparisons of acute toxicity (LD50) with carcinogenic potency show that they are correlated, but the correlation may in part be an artifact, since doses used in the NCI/NTP carcinogenesis bioassays are toxic and because reliable measures of potency can only be derived for positive carcinogenic responses. The high correlations for certain classes of chemicals and the relationship of chronic toxicity to positive carcinogenic finding suggest that these relationships are more than spurious. Since toxicities in different species are highly correlated, these findings imply that carcinogenicities in different species are also correlated.

Integrated care and electronic transmission of prescriptions: experience of the evaluation of ETP pilots

The NHS Care Records Service will connect more than 30,000 GPs and 270 acute, community and mental health NHS trusts in a single, secure national system. This will support electronic transmission of prescriptions (ETP) to pharmacies linked to the NHS Care Records Service spine and also to the national Prescription Pricing Authority (PPA). This article reflects on the experience of evaluating three pilot implementations of ETP in England in 2002, and concludes that some evaluation findings may be relevant not only to ETP messaging but also to electronic health record (EHR) systems and hence to the broader implications of implementing the NHS Care Records Service.

Patient information leaflets: producing understandable PILs

The concept of the informed health-care ‘consumer’ rests on the availability of comprehensible information. While various bodies have made information available, its quality is mixed. Information is sometimes untrustworthy, incomprehensible, or simply forgotten by patients. An understandable record of advice is more likely to bring about compliance with treatment and lessen the need to revisit the surgery. This is a report of the revision of health-care information leaflets and their testing on 59 volunteers (61-81 years old). Presentation, reading ease and understanding were considered. The goal of making health-care information comprehensible was achieved. Guidelines for revising such material are described and illustrated. The informed consumer goal may be achievable if writers of health-care information attend to communication as much as to the adequacy of their medical advice.

Telegenetic medicine: improved access to services in an underserved area

We used telemedicine to improve genetics services to patients in the rural northwestern region of Florida. Patients were first seen via videoconference by a genetic counsellor, who obtained family and medical history. A local paediatrician then performed the physical examination, and a plan for evaluation was established. The videoconferencing equipment was connected at a bandwidth of 384 kbit/s, using three ISDN lines. During the first three telemedicine clinics, seven patients were evaluated and then returned to the centre for a face-to-face consultation with the clinical geneticist. No new diagnoses were made face-to-face that had not been identified by telemedicine. No diagnoses made by telemedicine were judged to be wrong when the child was evaluated face-to-face. During a two-year study of patient satisfaction with 12 telegenetics clinics, the 50 families evaluated via videoconferencing were asked to complete surveys; 40 surveys were returned (a response rate of 80%). All individuals either strongly agreed or agreed that the evaluation of their child was appropriate, sufficient and sufficiently protective of their child's privacy. The waiting time for a new patient consultation with the clinical genetics team was 16.9 months (SD 1.9) at the start and 3.0 months (SD 1.0) at the end of the trial period. The difference was significant ( t-test, P<0.0001). Telegenetics allows more rapid assurance that a genetic syndrome has not been identified, or a quicker initial evaluation and diagnosis for children who do have an identifiable genetic syndrome.

Toll-IL1 receptor-mediated innate immune responses vary across HBV genotype and predict treatment response to pegylated-IFN in HBeAg-positive CHB patients

Patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) have suppressed TLR2 expression, function and cytokine production. The aim of this study was to explore the importance of hepatitis B virus (HBV) genotype in innate immune responses and investigate whether Toll-like receptor (TLR) expression/function has potential roles as predictive biomarkers of successful therapy with pegylated interferon (Peg-IFN) therapy of HBeAg seroconversion in HBeAg-positive patients. We showed that as early as 4 weeks after initiation of Peg-IFN, future HBeAg seroconverters had significantly elevated levels of TLR2 expression on monocytes. TLR2-associated IL-6 production at baseline and week 4 of therapy and TLR4 IL-6 production at week 4 were also markedly elevated in HBeAg seroconverters. HBV genotype also influenced treatment response, with genotypes A and B more likely to seroconvert than D. We were able to demonstrate that these differences were due in part to the interaction of the specific HBeAg proteins with TLR pathway adaptor molecules, and these interactions were genotype dependent. HBeAg-mediated modulation of TLR signalling was also observed in Huh7 cells, following stimulation with Pam3Cys. Importantly, the addition of IFN-α to TLR2-stimulated cells cotransfected with an HBeAg expression plasmid reversed HBeAg-mediated suppression of hepatocytes. These findings demonstrate that patients with an activated inflammatory response are much more likely to respond to IFN therapy, with TLR responses showing promise as potential biomarkers of HBeAg seroconversion in this setting. Furthermore, our findings suggest there is differential genotype-specific HBeAg suppression of innate signalling pathways which may account for some of the clinical differences observed across the CHB spectrum.

Abstract P6-03-04: Amplification of the WHSC1L1 oncogene regulates expression and estrogen-independent activation of ERα in SUM-44 breast cancer cells and is associated with ERα over expression in breast cancer

The 8p11-p12 amplicon occurs in approximately 15% of breast cancers and occurs almost exclusively in aggressive luminal B type tumors. Our lab and other labs have identified the WHSC1L1 oncogene as a driving oncogene from this region with potent transforming activity. In the present studies, we found that over expression of WHSC1L1 is linked to over expression of the ESR1 and ERα protein in the SUM-44 breast cancer cell line, and also in primary human breast cancer specimens. Knockdown of WHSC1L1, and particularly the short isoform of WHSC1L1, had a dramatic effect on ESR1 mRNA and ERα protein levels. SUM-44 cells do not require exogenous estrogen for continuous growth in vitro; however these cells are dependent on ERα expression as determined from ESR1 knockdown experiments, and potent growth inhibition and ERα degradation following exposure to the selective estrogen receptor degrader (SERD) fulvestrant. ChIP-Seq experiments utilizing ERα antibodies demonstrated potent ERα binding to chromatin in SUM-44 cells under estrogen-free conditions. ERα bound to ERE and FOXA1 binding motifs under estrogen-free conditions and regulated expression of number of well-known estrogen responsive genes. Short term treatment with estradiol enhanced binding of ERα to chromatin and influenced expression of many of the same genes expressed and to which ERα was bound under estrogen-free conditions. Finally, knockdown of WHSC1L1 in SUM-44 cells resulted in loss of ERα binding to chromatin under estrogen-free conditions; however treatment estradiol restored ERα binding to chromatin at key estrogen-response elements and genes. These results indicate the SUM-44 cells are a good model for a subset of luminal B breast cancers that have the 8p11-p12 amplicon, over express the WHSC1L1 oncogene, and over express ERα that is independent of estrogen for binding to chromatin and regulation of gene expression. Dependence on ERα activity for growth and survival of breast cancer cells but independence of estradiol is a major cause of breast cancer mortality as such cells become non-responsive to current hormonally based therapies.

Citation Format: Ethier SP, Irish J, Mills J, Ivey B, Hardiam G, Wilson R, Domkowski A, Guest S. Amplification of the WHSC1L1 oncogene regulates expression and estrogen-independent activation of ERα in SUM-44 breast cancer cells and is associated with ERα over expression in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-03-04.