51
|
Bremner PR, Birk R, Brealey N, Ismaila AS, Zhu CQ, Lipson DA. Single-inhaler fluticasone furoate/umeclidinium/vilanterol versus fluticasone furoate/vilanterol plus umeclidinium using two inhalers for chronic obstructive pulmonary disease: a randomized non-inferiority study. Respir Res 2018; 19:19. [PMID: 29370819 PMCID: PMC5785849 DOI: 10.1186/s12931-018-0724-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/16/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) 100/62.5/25 μg has been shown to improve lung function and health status, and reduce exacerbations, versus budesonide/formoterol in patients with chronic obstructive pulmonary disease (COPD). We evaluated the non-inferiority of single-inhaler FF/UMEC/VI versus FF/VI + UMEC using two inhalers. METHODS Eligible patients with COPD (aged ≥40 years; ≥1 moderate/severe exacerbation in the 12 months before screening) were randomized (1:1; stratified by the number of long-acting bronchodilators [0, 1 or 2] per day during run-in) to receive 24-week FF/UMEC/VI 100/62.5/25 μg and placebo or FF/VI 100/25 μg + UMEC 62.5 μg; all treatments/placebo were delivered using the ELLIPTA inhaler once-daily in the morning. Primary endpoint: change from baseline in trough forced expiratory volume in 1 s (FEV1) at Week 24. The non-inferiority margin for the lower 95% confidence limit was set at - 50 mL. RESULTS A total of 1055 patients (844 [80%] of whom were enrolled on combination maintenance therapy) were randomized to receive FF/UMEC/VI (n = 527) or FF/VI + UMEC (n = 528). Mean change from baseline in trough FEV1 at Week 24 was 113 mL (95% CI 91, 135) for FF/UMEC/VI and 95 mL (95% CI 72, 117) for FF/VI + UMEC; the between-treatment difference of 18 mL (95% CI -13, 50) confirmed FF/UMEC/VI's was considered non-inferior to FF/VI + UMEC. At Week 24, the proportion of responders based on St George's Respiratory Questionnaire Total score was 50% (FF/UMEC/VI) and 51% (FF/VI + UMEC); the proportion of responders based on the Transitional Dyspnea Index focal score was similar (56% both groups). A similar proportion of patients experienced a moderate/severe exacerbation in the FF/UMEC/VI (24%) and FF/VI + UMEC (27%) groups; the hazard ratio for time to first moderate/severe exacerbation with FF/UMEC/VI versus FF/VI + UMEC was 0.87 (95% CI 0.68, 1.12). The incidence of adverse events was comparable in both groups (48%); the incidence of serious adverse events was 10% (FF/UMEC/VI) and 11% (FF/VI + UMEC). CONCLUSIONS Single-inhaler triple therapy (FF/UMEC/VI) is non-inferior to two inhalers (FF/VI + UMEC) on trough FEV1 change from baseline at 24 weeks. Results were similar on all other measures of efficacy, health-related quality of life, and safety. TRIAL REGISTRATION GSK study CTT200812; ClinicalTrials.gov NCT02729051 (submitted 31 March 2016).
Collapse
Affiliation(s)
| | - Ruby Birk
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | | | - Afisi S. Ismaila
- GSK, Collegeville, PA USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
| | | | - David A. Lipson
- GSK, 709 Swedeland Road, UW2531, King of Prussia, PA 19406 USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| |
Collapse
|
52
|
Balkissoon R. New Treatment Options for COPD: How Do We Decide Phenotypes, Endotypes or Treatable Traits? CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:72-80. [PMID: 29629407 DOI: 10.15326/jcopdf.5.1.2018.0128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
53
|
Malerba M, Nardin M, Santini G, Mores N, Radaeli A, Montuschi P. Single-inhaler triple therapy utilizing the once-daily combination of fluticasone furoate, umeclidinium and vilanterol in the management of COPD: the current evidence base and future prospects. Ther Adv Respir Dis 2018; 12:1753466618760779. [PMID: 29537340 PMCID: PMC5941662 DOI: 10.1177/1753466618760779] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/31/2018] [Indexed: 12/13/2022] Open
Abstract
Maintenance pharmacological treatment for stable chronic obstructive pulmonary disease (COPD) is based on inhaled drugs, including long-acting muscarinic receptor antagonists (LAMA), long-acting β2-adrenoceptor agonists (LABA) and inhaled corticosteroids (ICS). Inhaled pharmacological treatment can improve patients' daily symptoms and reduce decline of pulmonary function and acute exacerbation rate. Treatment with all three inhaled drug classes is reserved for selected, more severe, patients with COPD when symptoms are not sufficiently controlled by dual LABA/LAMA therapy and exacerbations are frequent. This review focuses on the role of single-inhaler triple therapy with once-daily fluticasone furoate/umeclidinium/vilanterol fixed-dose combination, which is in phase III clinical development for maintenance treatment of severe-to-very severe COPD. In this review, we summarize evidence providing the rationale for its use in COPD and discuss the gaps to be filled in this pharmacotherapeutic area.
Collapse
Affiliation(s)
- Mario Malerba
- Department of Translational Medicine-Respiratory Medicine, University of Piemonte Orientale, Novara/Vercelli, Italy
| | - Matteo Nardin
- Department of Internal Medicine, University of Brescia, Brescia, Italy
| | - Giuseppe Santini
- Department of Pharmacology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation, Rome, Italy
| | - Nadia Mores
- Department of Pharmacology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation, Rome, Italy
| | - Alessandro Radaeli
- Department of Emergency Medicine, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Paolo Montuschi
- Department of Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Agostino Gemelli, University Hospital Foundation, Largo Francesco Vito, 1 – 00168, Rome, Italy
| |
Collapse
|
54
|
Ariel A, Altraja A, Belevskiy A, Boros PW, Danila E, Fležar M, Koblizek V, Fridlender ZG, Kostov K, Krams A, Milenkovic B, Somfay A, Tkacova R, Tudoric N, Ulmeanu R, Valipour A. Inhaled therapies in patients with moderate COPD in clinical practice: current thinking. Int J Chron Obstruct Pulmon Dis 2017; 13:45-56. [PMID: 29317810 PMCID: PMC5743110 DOI: 10.2147/copd.s145573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COPD is a complex, heterogeneous condition. Even in the early clinical stages, COPD carries a significant burden, with breathlessness frequently leading to a reduction in exercise capacity and changes that correlate with long-term patient outcomes and mortality. Implementation of an effective management strategy is required to reduce symptoms, preserve lung function, quality of life, and exercise capacity, and prevent exacerbations. However, current clinical practice frequently differs from published guidelines on the management of COPD. This review focuses on the current scientific evidence and expert opinion on the management of moderate COPD: the symptoms arising from moderate airflow obstruction and the burden these symptoms impose, how physical activity can improve disease outcomes, the benefits of dual bronchodilation in COPD, and the limited evidence for the benefits of inhaled corticosteroids in this disease. We emphasize the importance of maximizing bronchodilation in COPD with inhaled dual-bronchodilator treatment, enhancing patient-related outcomes, and enabling the withdrawal of inhaled corticosteroids in COPD in well-defined patient groups.
Collapse
Affiliation(s)
- Amnon Ariel
- Emek Medical Center, Clalit Healthcare Services, Afula, Israel
| | - Alan Altraja
- Department of Pulmonary Medicine, University of Tartu
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Andrey Belevskiy
- Department of Pulmonology, Russian National Research Medical University, Moscow, Russia
| | - Piotr W Boros
- Lung Pathophysiology Department, National TB and Lung Diseases Research Institute, Warsaw, Poland
| | - Edvardas Danila
- Clinic of Infectious Chest Diseases, Dermatovenereology, and Allergology, Vilnius University, Centre of Pulmonology and Allergology, Vilnius University Hospital, Vilnius, Lithuania
| | - Matjaz Fležar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Vladimir Koblizek
- Department of Pneumology, University Hospital, Hradec Králové, Czech Republic
| | - Zvi G Fridlender
- Institute of Pulmonary Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Kosta Kostov
- Clinic of Pulmonary Diseases, Military Medical Academy, Sofia, Bulgaria
| | - Alvils Krams
- Medical Faculty of Latvian University, Riga East University Hospital, Riga, Latvia
| | - Branislava Milenkovic
- Clinic for Pulmonary Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Attila Somfay
- Department of Pulmonology, University of Szeged, Deszk, Hungary
| | - Ruzena Tkacova
- Department of Respiratory Medicine and Tuberculosis, Faculty of Medicine, PJ Safarik University, Košice, Slovakia
| | - Neven Tudoric
- School of Medicine, Dubrava University Hospital, Zagreb, Croatia
| | | | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
| |
Collapse
|
55
|
Calverley PMA, Magnussen H, Miravitlles M, Wedzicha JA. Triple Therapy in COPD: What We Know and What We Don't. COPD 2017; 14:648-662. [DOI: 10.1080/15412555.2017.1389875] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Centre for Lung Research, Grosshansdorf, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Jadwiga A. Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
56
|
Gillissen A, Kähler CM, Koczulla AR, Sauer R, Paparoupa M. [COPD-Management, a comprehensive review]. MMW Fortschr Med 2017; 159:32-43. [PMID: 29086259 DOI: 10.1007/s15006-017-9594-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- A Gillissen
- Kreiskliniken Reutlingen / Ermstalklinik, Med. Klinik III Innere Medizin/Pneumologie, Stuttgarter-Str. 100, D.72574, Reutlingen-Bad Urach, Deutschland.
| | - Christian M Kähler
- Klinik für Pneumologie, Beatmungsmedizin und Allergologie, Wangen im Allgäu, Deutschland
| | - A Rembert Koczulla
- Klinik für Pneumologie, Universitätsklinikum Gießen und Marburg, Marburg, Deutschland
| | | | - Maria Paparoupa
- Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, Deutschland
| |
Collapse
|
57
|
Banerji D, Fogel R, Patalano F. Indacaterol/glycopyrronium: a dual bronchodilator for COPD. Drug Discov Today 2017; 23:196-203. [PMID: 29079130 DOI: 10.1016/j.drudis.2017.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/13/2017] [Accepted: 10/18/2017] [Indexed: 12/15/2022]
Abstract
Indacaterol/glycopyrronium (IND/GLY) 110/50mcg was the first once-daily, long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combination (FDC) approved in Europe for the treatment of chronic obstructive pulmonary disease (COPD). Development of IND/GLY was driven by the need to improve the standard of care for patients with this disease, in terms of symptom control and exacerbation frequency. IGNITE, an adaptive, comprehensive, and innovative Phase 3 development program, demonstrated the efficacy of IND/GLY in optimising bronchodilation, reducing symptoms, and reducing exacerbations in patients with COPD. IGNITE challenged contemporary thinking about the pharmacological treatment and management of patients with this disease.
Collapse
Affiliation(s)
- Donald Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
| | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | |
Collapse
|
58
|
Lipson DA, Barnacle H, Birk R, Brealey N, Locantore N, Lomas DA, Ludwig-Sengpiel A, Mohindra R, Tabberer M, Zhu CQ, Pascoe SJ. Reply: "FULFIL an Unmet Need in Chronic Obstructive Pulmonary Disease" and "Triple Therapy in Chronic Obstructive Pulmonary Disease". Am J Respir Crit Care Med 2017; 196:1083-1084. [PMID: 28534669 DOI: 10.1164/rccm.201704-0818le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David A Lipson
- 1 GlaxoSmithKline King of Prussia, Pennsylvania.,2 University of Pennsylvania Philadelphia, Pennsylvania
| | | | - Ruby Birk
- 3 GlaxoSmithKline Uxbridge, United Kingdom
| | | | | | - David A Lomas
- 4 University College London London, United Kingdom and
| | | | | | | | | | | |
Collapse
|
59
|
Keir HR, Fong CJ, Dicker AJ, Chalmers JD. Profile of the ProAxsis active neutrophil elastase immunoassay for precision medicine in chronic respiratory disease. Expert Rev Mol Diagn 2017; 17:875-884. [DOI: 10.1080/14737159.2017.1374174] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Holly R Keir
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Christopher J Fong
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Alison J Dicker
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| |
Collapse
|
60
|
Monaco TJ, Hanania NA. Emerging inhaled long-acting beta-2 adrenoceptor agonists for the treatment of COPD. Expert Opin Emerg Drugs 2017; 22:285-299. [DOI: 10.1080/14728214.2017.1367382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Thomas J. Monaco
- Baylor College of Medicine, Section of Pulmonary and Critical Care Medicine, Houston, TX, USA
| | - Nicola A. Hanania
- Baylor College of Medicine, Section of Pulmonary and Critical Care Medicine, Houston, TX, USA
| |
Collapse
|
61
|
Ismaila AS, Birk R, Shah D, Zhang S, Brealey N, Risebrough NA, Tabberer M, Zhu CQ, Lipson DA. Once-Daily Triple Therapy in Patients with Advanced COPD: Healthcare Resource Utilization Data and Associated Costs from the FULFIL Trial. Adv Ther 2017; 34:2163-2172. [PMID: 28875459 PMCID: PMC5599456 DOI: 10.1007/s12325-017-0604-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Indexed: 11/27/2022]
Abstract
Introduction Chronic obstructive pulmonary disease is associated with a high healthcare resource and cost burden. Healthcare resource utilization was analyzed in patients with symptomatic chronic obstructive pulmonary disease at risk of exacerbations in the FULFIL study. Patients received either once-daily, single inhaler triple therapy (fluticasone furoate/umeclidinium/vilanterol) 100 µg/62.5 µg/25 µg or twice-daily dual inhaled corticosteroid/long-acting beta agonist therapy (budesonide/formoterol) 400 µg/12 µg. Methods FULFIL was a phase III, randomized, double-blind, double-dummy, multicenter study. Unscheduled contacts with healthcare providers were recorded by patients in a daily electronic diary; the costs of healthcare resource utilization were calculated post hoc using UK reference costs. Results Over 24 weeks, slightly fewer patients who received fluticasone furoate/umeclidinium/vilanterol (169/911; 18.6%) required contacts with healthcare providers compared with budesonide/formoterol (180/899; 20.0%). Over 52 weeks in an extension population, fewer patients who received fluticasone furoate/umeclidinium/vilanterol required unscheduled contacts with healthcare providers compared with budesonide/formoterol (25.2% vs. 32.7%). Non-drug costs per treated patient per year were lower in the fluticasone furoate/umeclidinium/vilanterol group than the budesonide/formoterol group over 24 and 52 weeks (£653.80 vs. £763.32 and £749.22 vs. £988.03, respectively), with the total annualized cost over 24 weeks being slightly greater for fluticasone furoate/umeclidinium/vilanterol than budesonide/formoterol (£1,289.35 vs. £1,267.45). Conclusions This healthcare resource utilization evidence suggests that, in a clinical trial setting over a 24- or 52-week timeframe, non-drug costs associated with management of a single inhaler fluticasone furoate/umeclidinium/vilanterol are lower compared with twice-daily budesonide/formoterol. Trial Registration ClinicalTrials.gov number: NCT02345161. Funding GSK Electronic supplementary material The online version of this article (doi:10.1007/s12325-017-0604-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Research Triangle Park, NC, USA.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Ruby Birk
- Respiratory Clinical Development, GSK, Stockley Park, Uxbridge, UK
| | - Dhvani Shah
- ICON Health Economics, ICON, New York, NY, USA
| | - Shiyuan Zhang
- Respiratory Research and Development, GSK, Collegeville, PA, USA
| | - Noushin Brealey
- Respiratory Clinical Development, GSK, Stockley Park, Uxbridge, UK
| | | | - Maggie Tabberer
- Value Evidence and Outcomes, GSK, Stockley Park, Uxbridge, UK
| | - Chang-Qing Zhu
- Respiratory Clinical Development, GSK, Stockley Park, Uxbridge, UK
| | - David A Lipson
- Respiratory Research and Development, GSK, King of Prussia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
62
|
Thomas M, Halpin DMG, Miravitlles M. When is dual bronchodilation indicated in COPD? Int J Chron Obstruct Pulmon Dis 2017; 12:2291-2305. [PMID: 28814857 PMCID: PMC5546730 DOI: 10.2147/copd.s138554] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Inhaled bronchodilator medications are central to the management of COPD and are frequently given on a regular basis to prevent or reduce symptoms. While short-acting bronchodilators are a treatment option for people with relatively few COPD symptoms and at low risk of exacerbations, for the majority of patients with significant breathlessness at the time of diagnosis, long-acting bronchodilators may be required. Dual bronchodilation with a long-acting β2-agonist and long-acting muscarinic antagonist may be more effective treatment for some of these patients, with the aim of improving symptoms. This combination may also reduce the rate of exacerbations compared with a bronchodilator-inhaled corticosteroid combination in those with a history of exacerbations. However, there is currently a lack of guidance on clinical indicators suggesting which patients should step up from mono- to dual bronchodilation. In this article, we discuss a number of clinical indicators that could prompt a patient and physician to consider treatment escalation, while being mindful of the need to avoid unnecessary polypharmacy. These indicators include insufficient symptomatic response, a sustained increased requirement for rescue medication, suboptimal 24-hour symptom control, deteriorating symptoms, the occurrence of exacerbations, COPD-related hospitalization, and reductions in lung function. Future research is required to provide a better understanding of the optimal timing and benefits of treatment escalation and to identify the appropriate tools to inform this decision.
Collapse
Affiliation(s)
- Mike Thomas
- Primary Care and Population Sciences, University of Southampton, Southampton
| | - David MG Halpin
- Department of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| |
Collapse
|
63
|
Papi A, Dokic D, Tzimas W, Mészáros I, Olech-Cudzik A, Koroknai Z, McAulay K, Mersmann S, Dalvi PS, Overend T. Fluticasone propionate/formoterol for COPD management: a randomized controlled trial. Int J Chron Obstruct Pulmon Dis 2017; 12:1961-1971. [PMID: 28740376 PMCID: PMC5505160 DOI: 10.2147/copd.s136527] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To evaluate fluticasone propionate/formoterol (FP/FORM) in COPD. PATIENTS AND METHODS COPD patients with forced expiratory volume in 1 s (FEV1) ≤50% predicted and ≥1 moderate/severe COPD exacerbation in the last 12 months were randomized to FP/FORM 500/20 or 250/10 µg bid, or formoterol (FORM) 12 µg bid for 52 weeks. The primary outcome was the annualized rate of moderate/severe COPD exacerbations. RESULTS In total, 1,765 patients were randomized. There were fewer discontinuations with FP/FORM 500/20 µg (20.6%) and 250/10 µg (24.0%) compared with FORM (26.1%). None of the two FP/FORM doses reduced the moderate/severe exacerbation rate versus FORM (rate ratios [RR]: 0.93; P≤0.402). There was a trend toward a lower moderate/severe exacerbation rate with FP/FORM 500/20 µg versus FORM in patients with ≥2 exacerbations in the preceding year (RR: 0.79; P=0.084). Pre- and post-dose FEV1 and forced vital capacity were greater with FP/FORM 500/20 µg versus FORM (P≤0.039). There was a trend toward a lower EXAcerbations of Chronic pulmonary disease Tool (EXACT) exacerbation rate with FP/FORM 500/20 µg versus FORM (RR: 0.87; P=0.077). There were more St George's Respiratory Questionnaire for COPD (SGRQ-C) responders with FP/FORM 500/20 µg than FORM (odds ratios [OR] at weeks 6, 23 and 52 ≥1.28; P≤0.054). EXACT-respiratory symptoms total and breathlessness scores were lower with both FP/FORM 500/20 µg and 250/10 µg versus FORM (P≤0.066). Acute β2-agonist-induced effects and 24-hour Holter findings were similar for all treatments. Mean 24-hour urinary cortisol was similarly reduced with both FP/FORM doses. Radiologically confirmed pneumonia was seen in 2.4%, 3.2% and 1.5% of FP/FORM 500/20 µg, FP/FORM 250/10 µg and FORM-treated patients, respectively. Adverse events were otherwise similar across treatment groups. CONCLUSION FP/FORM did not reduce exacerbation rates versus FORM. Numerical benefits were observed with FP/FORM 500/20 µg versus FORM for secondary variables, including lung function, EXACT exacerbations, SGRQ-C and EXACT-respiratory symptoms total and breathlessness scores. Few efficacy differences were evident between FP/FORM 250/10 µg and FORM. Pneumonia was more frequent in FP/FORM-treated patients, although the absolute difference was low. Adverse events were otherwise similar between treatments.
Collapse
Affiliation(s)
- A Papi
- Department of Internal and CardioRespiratory Medicine, Reseach Center on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | - D Dokic
- Clinic of Pulmology and Allergy, Clinical Centre, Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia
| | - W Tzimas
- Pneumologische Praxis, München, Germany
| | - I Mészáros
- Coral Szakorvosi Centrum, Budapest, Hungary
| | - A Olech-Cudzik
- Ostrowieckie Centrum Medyczne Spółka, Ostrowiec Swietokrzyski, Poland
| | - Z Koroknai
- PAREXEL International, Global Medical Services, Budapest, Hungary
| | - K McAulay
- Medical Operations, Mundipharma Research Limited, Cambridge, UK
| | - S Mersmann
- Biostatistics and Clinical Data Science, Mundipharma Research GmbH & Co. KG, Limburg, Germany
| | - PS Dalvi
- Medical Science - Respiratory, Mundipharma Research Limited, Cambridge, UK
| | - T Overend
- Medical Science - Respiratory, Mundipharma Research Limited, Cambridge, UK
| |
Collapse
|
64
|
Ni H, Htet A, Moe S. Umeclidinium bromide versus placebo for people with chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2017; 2017:CD011897. [PMID: 28631387 PMCID: PMC6481854 DOI: 10.1002/14651858.cd011897.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with chronic obstructive pulmonary disease (COPD) have poor quality of life, reduced survival, and accelerated decline in lung function, especially associated with acute exacerbations, leading to high healthcare costs. Long-acting bronchodilators are the mainstay of treatment for symptomatic improvement, and umeclidinium is one of the new long-acting muscarinic antagonists approved for treatment of patients with stable COPD. OBJECTIVES To assess the efficacy and safety of umeclidinium bromide versus placebo for people with stable COPD. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, the World Health Organization (WHO) trials portal, and the GlaxoSmithKline (GSK) Clinical Study Register, using prespecified terms, as well as the reference lists of all identified studies. Searches are current to April 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) of parallel design comparing umeclidinium bromide versus placebo in people with COPD, for at least 12 weeks. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. If we noted significant heterogeneity in the meta-analyses, we subgrouped studies by umeclidinium dose. MAIN RESULTS We included four studies of 12 to 52 weeks' duration, involving 3798 participants with COPD. Mean age of participants ranged from 60.1 to 64.6 years; most were males with baseline mean smoking pack-years of 39.2 to 52.3. They had moderate to severe COPD and baseline mean post-bronchodilator forced expiratory volume in one second (FEV1) ranging from 44.5% to 55.1% of predicted normal. As all studies were systematically conducted according to prespecified protocols, we assessed risk of selection, performance, detection, attrition, and reporting biases as low.Compared with those given placebo, participants in the umeclidinium group had a lesser likelihood of developing moderate exacerbations requiring a short course of steroids, antibiotics, or both (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.46 to 0.80; four studies, N = 1922; GRADE: high), but not specifically requiring hospitalisations due to severe exacerbations (OR 0.86, 95% CI 0.25 to 2.92; four studies, N = 1922, GRADE: low). The number needed to treat for an additional beneficial outcome (NNTB) to prevent an acute exacerbation requiring steroids, antibiotics, or both was 18 (95% CI 13 to 37). Quality of life was better in the umeclidinium group (mean difference (MD) -4.79, 95% CI -8.84 to -0.75; three studies, N = 1119), and these participants had a significantly higher chance of achieving a minimal clinically important difference of at least four units in St George's Respiratory Questionnaire (SGRQ) total score compared with those in the placebo group (OR 1.45, 95% CI 1.16 to 1.82; three studies, N = 1397; GRADE: moderate). The NNTB to achieve one person with a clinically meaningful improvement was 11 (95% CI 7 to 29). The likelihood of all-cause mortality, non-fatal serious adverse events (OR 1.33; 95% CI 0.89 to 2.00; four studies, N = 1922, GRADE: moderate), and adverse events (OR 1.06, 95% CI 0.85 to 1.31; four studies, N = 1922; GRADE: moderate) did not differ between umeclidinium and placebo groups. The umeclidinium group demonstrated significantly greater improvement in change from baseline in trough FEV1 compared with the placebo group (MD 0.14, 95% CI 0.12 to 0.17; four studies, N = 1381; GRADE: high). Symptomatic improvement was more likely in the umeclidinium group than in the placebo group, as determined by Transitional Dyspnoea Index (TDI) focal score (MD 0.76, 95% CI 0.43 to 1.09; three studies, N = 1193), and the chance of achieving a minimal clinically important difference of at least one unit improvement was significantly higher with umeclidinium than with placebo (OR 1.71, 95% CI 1.37 to 2.15; three studies, N = 1141; GRADE: high). The NNTB to attain one person with clinically important symptomatic improvement was 8 (95% CI 5 to 14). The likelihood of rescue medication usage (change from baseline in the number of puffs per day) was significantly less for the umeclidinium group than for the placebo group (MD -0.45, 95% CI -0.76 to -0.14; four studies, N = 1531). AUTHORS' CONCLUSIONS Umeclidinium reduced acute exacerbations requiring steroids, antibiotics, or both, although no evidence suggests that it decreased the risk of hospital admission due to exacerbations. Moreover, umeclidinium demonstrated significant improvement in quality of life, lung function, and symptoms, along with lesser use of rescue medications. Studies reported no differences in adverse events, non-fatal serious adverse events, or mortality between umeclidinium and placebo groups; however, larger studies would yield a more precise estimate for these outcomes.
Collapse
Affiliation(s)
- Han Ni
- Faculty of Medicine, SEGi UniversityInternal MedicineHospital Sibu, Jalan Ulu OyaSibuSarawakMalaysia96000
| | - Aung Htet
- No. 2 Defence Services General Hospital (1000 bedded)Department of RadiologyNay Pyi TawMyanmar
| | - Soe Moe
- Faculty of MedicineDepartment of Community MedicineMelaka‐Manipal Medical College (MMMC)Jalan Batu HamparMelakaMelakaMalaysia75150
| | | |
Collapse
|
65
|
Miravitlles M, Anzueto A, Jardim JR. Optimizing bronchodilation in the prevention of COPD exacerbations. Respir Res 2017; 18:125. [PMID: 28633665 PMCID: PMC5477752 DOI: 10.1186/s12931-017-0601-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/29/2017] [Indexed: 02/03/2023] Open
Abstract
The natural disease course of chronic obstructive pulmonary disease (COPD) is often punctuated by exacerbations: acute events of symptom worsening associated with significant morbidity and healthcare resource utilization; reduced quality of life; and increased risk of hospitalization and death. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend that patients at risk of exacerbations (GOLD Groups C and D) receive a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA)/LAMA combination, respectively, as preferred initial treatments. The latter recommendation is based on recent trial evidence demonstrating the superior efficacy of a fixed-dose LABA/LAMA over an inhaled corticosteroid (ICS)/LABA in exacerbation prevention. ICS in combination with a LABA is also indicated for prevention of exacerbations, but the use of ICS is associated with an increased risk of adverse events such as pneumonia, and offers limited benefits beyond those provided by LABA or LAMA monotherapy. In this review, we examine evidence from a number of pivotal studies of LABAs and LAMAs, administered as monotherapy or as part of dual or triple combination therapy, with a specific focus on their effect on exacerbations. We also discuss a new proposed treatment paradigm for the management of COPD that takes into account this recent evidence and adopts a more cautious approach to the use of ICS. In alignment with GOLD 2017, we suggest that ICS should be reserved for patients with concomitant asthma or in whom exacerbations persist despite treatment with LABA/LAMA.
Collapse
Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antonio Anzueto
- University of Texas Health Science Center, and South Texas Veterans Health Care System, San Antonio, TX USA
| | - José R. Jardim
- Respiratory Division, Escola Paulista de Medicina / Federal University de São Paulo, São Paulo, Brazil
| |
Collapse
|
66
|
Rabe KF, Watz H. Chronic obstructive pulmonary disease. Lancet 2017; 389:1931-1940. [PMID: 28513453 DOI: 10.1016/s0140-6736(17)31222-9] [Citation(s) in RCA: 602] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/09/2017] [Accepted: 02/14/2017] [Indexed: 02/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) kills more than 3 million people worldwide every year. Despite progress in the treatment of symptoms and prevention of acute exacerbations, few advances have been made to ameliorate disease progression or affect mortality. A better understanding of the complex disease mechanisms resulting in COPD is needed. Smoking cessation programmes, increasing physical activity, and early detection and treatment of comorbidities are further key components to reduce the burden of the disease. However, without a global political and economic effort to reduce tobacco use, to regulate environmental exposure, and to find alternatives to the massive use of biomass fuel, COPD will remain a major health-care problem for decades to come.
Collapse
Affiliation(s)
- Klaus F Rabe
- LungenClinic Grosshansdorf, Airway Research Centre North, German Centre for Lung Research, Grosshansdorf, Germany; Department of Medicine, Christian Albrechts University Kiel, Kiel, Germany.
| | - Henrik Watz
- Pulmonary Research Institute, Airway Research Centre North, German Centre for Lung Research, Grosshansdorf, Germany
| |
Collapse
|
67
|
Calverley PMA. A Light in the Darkness? The FLAME Trial, Blood Eosinophils, and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2017; 195:1125-1127. [DOI: 10.1164/rccm.201703-0560ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Peter M. A. Calverley
- Institute of Ageing and Chronic DiseaseUniversity of LiverpoolLiverpool, United Kingdom
| |
Collapse
|
68
|
Miravitlles M, D'Urzo A, Singh D, Koblizek V. Pharmacological strategies to reduce exacerbation risk in COPD: a narrative review. Respir Res 2016; 17:112. [PMID: 27613392 PMCID: PMC5018159 DOI: 10.1186/s12931-016-0425-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 08/20/2016] [Indexed: 01/17/2023] Open
Abstract
Identifying patients at risk of exacerbations and managing them appropriately to reduce this risk represents an important clinical challenge. Numerous treatments have been assessed for the prevention of exacerbations and their efficacy may differ by patient phenotype. Given their centrality in the treatment of COPD, there is strong rationale for maximizing bronchodilation as an initial strategy to reduce exacerbation risk irrespective of patient phenotype. Therefore, in patients assessed as frequent exacerbators (>1 exacerbation/year) we propose initial bronchodilator treatment with a long-acting muscarinic antagonist (LAMA)/ long-acting β2-agonist (LABA). For those patients who continue to experience >1 exacerbation/year despite maximal bronchodilation, we advocate treating according to patient phenotype. Based on currently available data on adding inhaled corticosteroids (ICS) to a LABA, ICS might be added to a LABA/LAMA combination in exacerbating patients who have an asthma-COPD overlap syndrome or high blood eosinophil counts, while in exacerbators with chronic bronchitis, consideration should be given to treating with a phosphodiesterase (PDE)-4 inhibitor (roflumilast) or high-dose mucolytic agents. For those patients who experience frequent bacterial exacerbations and/or bronchiectasis, addition of mucolytic agents or a macrolide antibiotic (e.g. azithromycin) should be considered. In all patients at risk of exacerbations, pulmonary rehabilitation should be included as part of a comprehensive management plan.
Collapse
Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital General Universitari Vall d'Hebron, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Anthony D'Urzo
- Department of Family and Community Medicine, University of Toronto, 1670 Dufferin Street, Suite 107, Toronto, ON, M6H 3M2, Canada
| | - Dave Singh
- University of Manchester, Medicines Evaluation Unit, University Hospital of South Manchester Foundation Trust, Southmoor Road, Manchester, M23 9QZ, UK
| | - Vladimir Koblizek
- Department of Pneumology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Simkova 870, Hradec Kralove 1, 500 38, Czech Republic
| |
Collapse
|