Intolerance to roflumilast in real-life clinical practice

Inhibitory effect of roflumilast on experimental periodontitis

BACKGROUND

Phosphodiesterase-4 (PDE4) has been identified as a valid therapeutic target in several inflammatory diseases. In this study, we assessed PDE4 in gingival tissue from patients with chronic periodontitis and evaluated the therapeutic effects of the PDE4 inhibitor, roflumilast, in an experimental rat model of periodontitis.

METHODS

Gingival tissue specimens from 20 healthy subjects and 20 patients with periodontitis were collected, and the mRNA expression levels of PDE4, interleukin (IL)-1β, and IL-6 were assessed. Ninety rats were divided randomly into three groups (30 per group): non-ligature group, ligature-induced periodontitis group (L), and ligature-induced periodontitis with roflumilast administered group (5 mg/kg/d) (L+R). Rats were euthanized on days 3, 8, and 14. Alveolar bone resorption was analyzed using microcomputed tomography. Inflammation and osteoclast number were analyzed histologically. Finally, the mRNA expression levels of PDE-4, IL-1β, IL-6, tumor necrosis factor (TNF)-α, and nuclear factor kappa B (NF-κB) were assessed in the rat gingival tissue.

RESULTS

The mRNA expression levels of PDE4, IL-1β, and IL-6 in the gingiva were significantly higher in patients with periodontitis compared with healthy individuals (P <0.05). Alveolar bone loss, degree of inflammation, number of TRAP-positive multinucleated osteoclasts, and mRNA expression levels of IL-1β, IL-6, TNF-α, NF-κB, and PDE4 in the L+R group were significantly lower than those in the L group (P <0.05).

CONCLUSIONS

PDE4 expression was increased in the gingiva of patients with periodontitis. Roflumilast may decrease alveolar bone loss and the expression of inflammatory cytokines in rats with ligature-induced periodontitis.

Efficacy and safety of CHF6001, a novel inhaled PDE4 inhibitor in COPD: the PIONEER study

Background

This study evaluated the efficacy, safety and tolerability of the novel inhaled phosphodiesterase-4 inhibitor CHF6001 added-on to formoterol in patients with chronic obstructive pulmonary disease (COPD).

Methods

Randomised, double-blind, placebo- and active-controlled, parallel-group study. Eligible patients had symptomatic COPD, post-bronchodilator forced expiratory volume in 1 s (FEV₁) 30–70% predicted, and history of ≥1 moderate/severe exacerbation. Patients were randomised to extrafine CHF6001 400, 800, 1200 or 1600 μg twice daily (BID), budesonide, or placebo for 24 weeks. Primary objectives: To investigate CHF6001 dose-response for pre-dose FEV₁ after 12 weeks, and to identify the optimal dose. Moderate-to-severe exacerbations were a secondary endpoint.

Results

Of 1130 patients randomised, 91.9% completed. Changes from baseline in pre-dose FEV₁ at Week 12 were small in all groups (including budesonide), with no CHF6001 dose-response, and no significant treatment–placebo differences. For moderate-to-severe exacerbations, CHF6001 rate reductions versus placebo were 13–28% (non-significant). In post-hoc analyses, CHF6001 effects were larger in patients with a chronic bronchitis phenotype (rate reductions versus placebo 24–37%; non-significant), and were further increased in patients with chronic bronchitis and eosinophil count ≥150 cells/μL (49–73%, statistically significant for CHF6001 800 and 1600 μg BID). CHF6001 was well tolerated with no safety signal (including in terms of gastrointestinal adverse events).

Conclusions

CHF6001 had no effect in the primary lung function analysis, although was well-tolerated with no gastrointestinal adverse event signal. Post-hoc analyses focused on exacerbation risk indicate specific patient subgroups who may receive particular benefit from CHF6001.

Trial registration

ClinicalTrials.gov (NCT02986321). Registered 8 Dec 2016.

Efficacy and safety profile of roflumilast in a real-world experience

Background

Roflumilast is the only phosphodiesterase enzyme 4 inhibitor approved in the treatment of chronic obstructive pulmonary disease (COPD) patients with chronic cough and sputum and a history of exacerbations. Real-world studies about the use of roflumilast are limited. Our aim was to assess the efficacy, safety and tolerability of roflumilast in the treatment of stable COPD, in a real-world setting.

Methods

From August 2014 to August 2017, medical records of all COPD patients who were prescribed roflumilast therapy in Akdeniz University Hospital were analyzed retrospectively. COPD patients were studied in terms of efficacy, safety, and drug discontinuation rate. Efficacy was evaluated as the effect of roflumilast on exacerbation and hospitalization rates of COPD compared to the pre-treatment period.

Results

Eighty-three COPD patients treated with roflumilast were included (mean age 66.2±9.3 years, 88.0% male). All the patients were chronic bronchitis and frequent exacerbator clinical phenotype and were classified in the Global Initiative for Chronic Obstructive Lung Disease categories C (n=17; 20.5%) and D (n=66; 79.5%). Mean duration of roflumilast use was 18.9±10.4 months. There was a significant decrease in both COPD exacerbations (2.7 vs. 1.16; P<0.001) and hospitalizations (0.77 vs. 0.32; P<0.001) in roflumilast users compared to the pre-treatment period. Of the patients, 22 (26.5%) experienced adverse events (AE) during their treatment period. The most frequently reported AEs were weight loss (10.8%), loss of appetite (10.8%) and nausea (8.4%). Serious or life-threatening AEs were not detected. Sixteen (19.3%) patients discontinued roflumilast because of AEs.

Conclusions

Roflumilast reduced exacerbations and hospitalizations in our real-world population with severe COPD. AEs are common and frequently leading to discontinuation of roflumilast therapy.

Effects of Roflumilast on Rehospitalization and Mortality in Patients

Introduction: Hospitalization for chronic obstructive pulmonary disease (COPD) exacerbation portends the greatest risk of rehospitalization and mortality. Treatments that prevent hospitalizations could significantly lessen COPD morbidity and mortality. Methods: We performed a prospective, randomized, double-blind, placebo-controlled study of roflumilast 500 ug daily versus placebo in patients hospitalized for acute COPD exacerbation. Primary outcome was time to all-cause mortality or non-elective rehospitalization at 180 days post-randomization. Secondary outcomes were death or hospitalization from a respiratory cause, quality of life, change in health status, forced expiratory volume in 1 second (FEV1) and roflumilast tolerance. Results: A total of 64 patients with moderate to severe COPD (FEV1, 37.6 ± 16.4% predicted; 61% female, 61.6 ± 7.9 years old) were assigned to roflumilast or placebo. No deaths occurred in the follow-up period. There was no difference in the time to first readmission between the roflumilast and placebo groups (46.1 days versus 47.3 days respectively, p=0.93). There were 29 and 30 readmissions in the roflumilast and placebo groups, respectively (p=0.47). The St George's Respiratory Questionnaire (SGRQ) decreased 10.8 points and 7.8 points in the roflumilast and placebo groups, respectively and were not different. EuroQuality of Life Five Dimension scale (EQ5D) scores improved, but not significantly in either group. Weight loss and nausea were more common with roflumilast but not different from placebo. Change in glycosylated hemoglobin percentage (HgbA1C%) was not different between groups. Sub-analysis for the impact of chronic bronchitis did not affect outcomes. Conclusion: In this pilot study conducted in patients hospitalized with an exacerbation of COPD, roflumilast did not affect time to all-cause rehospitalization, quality of life, FEV1 or any other measured parameter.

Phosphodiesterase-4 Inhibitors for the Treatment of Inflammatory Diseases

Phosphodiesterase-4 (PDE4), mainly present in immune cells, epithelial cells, and brain cells, manifests as an intracellular non-receptor enzyme that modulates inflammation and epithelial integrity. Inhibition of PDE4 is predicted to have diverse effects via the elevation of the level of cyclic adenosine monophosphate (cAMP) and the subsequent regulation of a wide array of genes and proteins. It has been identified that PDE4 is a promising therapeutic target for the treatment of diverse pulmonary, dermatological, and severe neurological diseases. Over the past decades, numerous PDE4 inhibitors have been designed and synthesized, among which roflumilast, apremilast, and crisaborole were approved for the treatment of inflammatory airway diseases, psoriatic arthritis, and atopic dermatitis, respectively. It is regrettable that the dramatic efficacies of a drug are often accompanied by adverse effects, such as nausea, emesis, and gastrointestinal reactions. However, substantial advances have been made to mitigate the adverse effects and obtain better benefit-to-risk ratio. This review highlights the dialectical role of PDE4 in drug discovery and the disquisitive details of certain PDE4 inhibitors to provide an overview of the topics that still need to be addressed in the future.