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Kaditis AG, Acton J, Fenton C, Kheirandish-Gozal L, Ner Z, Nevel R, Gozal D, Ohler A. Effect of Hypertonic Saline on Lung Function as Add-on Treatment in People With Cystic Fibrosis Receiving Dornase Alfa: A Cystic Fibrosis Foundation Patient Registry Analysis. Chest 2023; 164:860-871. [PMID: 37244586 DOI: 10.1016/j.chest.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Introduction of novel therapies for cystic fibrosis (CF) raises the question of whether traditional treatments can be withdrawn. Nebulized hypertonic saline (HS) potentially could be discontinued in patients receiving dornase alfa (DA). RESEARCH QUESTION In the era before modulators, did people with CF who are F508del homozygous (CFF508del) and who received DA and HS have better preserved lung function than those treated with DA only? STUDY DESIGN AND METHODS Retrospective analysis of the Cystic Fibrosis Foundation Patient Registry data (2006-2014). Among 13,406 CFF508del with data for at least 2 consecutive years, 1,241 CFF508del had spirometry results and were treated with DA for 1 to 5 years without DA or HS during the preceding (baseline) year. Absolute FEV1 % predicted change while receiving DA and HS, relative to treatment with DA only, was the main outcome. A marginal structural model was applied to assess the effect of 1 to 5 years of HS treatment while controlling for time-dependent confounding. RESULTS Of 1,241 CFF508del, 619 patients (median baseline age, 14.6 years; interquartile range, 6-53 years) received DA only and 622 patients (median baseline age, 14.55 years; interquartile range, 6-48.1 years) were treated with DA and HS for 1 to 5 years. After 1 year, patients receiving DA and HS showed FEV1 % predicted that averaged 6.60% lower than that in patients treated with DA only (95% CI, -8.54% to -4.66%; P < .001). Lower lung function in the former relative to the latter persisted throughout follow-up, highlighting confounding by indication. After accounting for baseline age, sex, race, DA use duration, baseline and previous year's FEV1 % predicted, and time-varying clinical characteristics, patients treated with DA and HS for 1 to 5 years were similar to those treated with DA only regarding FEV1 % predicted (year 1: mean FEV1 % predicted change, +0.53% [95% CI, -0.66% to +1.71%; P = .38]; year 5: mean FEV1 % predicted change, -1.82% [95% CI, -4.01% to +0.36%; P = .10]). INTERPRETATION In the era before modulators, CFF508del showed no significant difference in lung function when nebulized HS was added to DA for 1 to 5 years.
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Affiliation(s)
- Athanasios G Kaditis
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Department of Child Health, University of Missouri School of Medicine, MUHC Children's Hospital, Columbia, MO; Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO.
| | - James Acton
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Department of Child Health, University of Missouri School of Medicine, MUHC Children's Hospital, Columbia, MO
| | - Connie Fenton
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Department of Child Health, University of Missouri School of Medicine, MUHC Children's Hospital, Columbia, MO
| | - Leila Kheirandish-Gozal
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Department of Child Health, University of Missouri School of Medicine, MUHC Children's Hospital, Columbia, MO; Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO
| | - Zarah Ner
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Department of Child Health, University of Missouri School of Medicine, MUHC Children's Hospital, Columbia, MO
| | - Rebekah Nevel
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Department of Child Health, University of Missouri School of Medicine, MUHC Children's Hospital, Columbia, MO
| | - David Gozal
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Department of Child Health, University of Missouri School of Medicine, MUHC Children's Hospital, Columbia, MO; Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO
| | - Adrienne Ohler
- Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO
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Mayer-Hamblett N, Ratjen F, Russell R, Donaldson SH, Riekert KA, Sawicki GS, Odem-Davis K, Young JK, Rosenbluth D, Taylor-Cousar JL, Goss CH, Retsch-Bogart G, Clancy JP, Genatossio A, O'Sullivan BP, Berlinski A, Millard SL, Omlor G, Wyatt CA, Moffett K, Nichols DP, Gifford AH, Kloster M, Weaver K, Chapdu C, Xie J, Skalland M, Romasco M, Heltshe S, Simon N, VanDalfsen J, Mead A, Buckingham R, Seidel K, Midamba N, Couture L, Case BZ, Au W, Rockers E, Cooke D, Olander A, Bondick I, Johnson M, VanHousen L, Nicholson B, Omlor G, Parrish M, Roberts D, Head J, Carey J, Caverly L, Dangerfield J, Linnemann R, Fullmer J, Roman C, Mogayzel P, Reyes D, Harmala A, Lysinger J, Bergeron J, Virella-Lowell I, Brown P, Godusevic L, Casey A, Paquette L, Lahiri T, Sweet J, Donaldson S, Harris J, Parnell S, Szentpetery S, Froh D, Tharrington E, Jain M, Nelson R, Kadon S, McPhail G, McBennett K, Rone T, Dasenbrook E, Weaver D, Johnson T, McCoy K, Jain R, Mcleod M, Klosterman M, Sharma P, Jones A, Mueller G, Janney R, Taylor-Cousar J, Cross M, Hoppe J, Cahill J, Mukadam Z, Finto J, Schultz K, Villalta SD, Smith A, Millard S, Symington T, Graff G, Kitch D, Sanders D, Thompson M, Pena T, Teresi M, Gafford J, Schaeffer D, Mermis J, Scott L, Escobar H, Williams K, Dorman D, O'Sullivan B, Bethay R, Danov Z, Berlinski A, Turbeville K, Johannes J, Rodriguez A, Marra B, Zanni R, Morton R, Simeon T, Braun A, Dondlinger N, Biller J, Hubertz E, Antos N, Roth L, Billings J, Larson C, Balaji P, McNamara J, Clark T, Moffett K, Griffith R, Martinez N, Hussain S, Malveaux H, Egan M, Guzman C, DeCelie-Germana J, Galvin S, Savant A, Falgout N, Walker P, Demarco T, DiMango E, Ycaza M, Ballo J, Tirakitsoontorn P, Layish D, Serr D, Livingston F, Wooldridge S, Milla C, Spano J, Davis R, Elidemir O, Chittivelu S, Scott A, Alam S, Dorgan D, Butoryak M, Weiner D, Renna H, Wyatt C, Klein B, Stone A, Lessard M, Schechter MS, Johnson B, Scofield S, Liou T, Vroom J, Akong K, Gil M, Betancourt L, Singer J, Ly N, Moreno C, Aitken M, Gambol T, Genatossio A, Gibson R, Lambert A, Milton J, Rosenbluth D, Smith S, Green D, Hodge D, Fortner C, Forell M, Karlnoski R, Patel K, Daines C, Ryan E, Amaro-Galvez R, Dohanich E, Lennox A, Messer Z, Hanes H, Powell K, Polineni D. Discontinuation versus continuation of hypertonic saline or dornase alfa in modulator treated people with cystic fibrosis (SIMPLIFY): results from two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials. THE LANCET. RESPIRATORY MEDICINE 2023; 11:329-340. [PMID: 36343646 PMCID: PMC10065895 DOI: 10.1016/s2213-2600(22)00434-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Reducing treatment burden is a priority for people with cystic fibrosis, whose health has benefited from using new modulators that substantially increase CFTR protein function. The SIMPLIFY study aimed to assess the effects of discontinuing nebulised hypertonic saline or dornase alfa in individuals using the CFTR modulator elexacaftor plus tezacaftor plus ivacaftor (ETI). METHODS The SIMPLIFY study included two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials at 80 participating clinics across the USA in the Cystic Fibrosis Therapeutics Development Network. We included individuals with cystic fibrosis aged 12-17 years with percent predicted FEV1 (ppFEV1) of 70% or more, or those aged 18 years or older with ppFEV1 of 60% or more, if they had been taking ETI and either (or both) mucoactive therapies (≥3% hypertonic saline or dornase alfa) for at least 90 days before screening. Participants on both hypertonic saline and dornase alfa were randomly assigned to one of the two trials, and those on a single therapy were assigned to the applicable trial. All participants were then randomly assigned 1:1 to continue or discontinue therapy for 6 weeks using permuted blocks of varying size, stratified by baseline ppFEV1 (week 0; ≥90% or <90%), single or concurrent use of hypertonic saline and dornase alfa, previous SIMPLIFY study participation (yes or no), and age (≥18 or <18 years). For participants randomly assigned to continue their therapy during a given trial, this therapy was instructed to be taken at least once daily according to each participant's pre-existing, clinically prescribed regimen. Hypertonic saline concentration was required to be at least 3%. The primary objective for each trial was to determine whether discontinuing was non-inferior to continuing, measured by the 6-week change in ppFEV1 in the per-protocol population. We established a non-inferiority margin of -3% for the difference between groups in the 6-week change in ppFEV1. Safety outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT04378153. FINDINGS From Aug 25, 2020, to May 25, 2022, a total of 672 unique participants were screened for eligibility for one or both trials, resulting in 847 total random assignments across both trials with 594 unique participants. 370 participants were randomly assigned in the hypertonic saline trial and 477 in the dornase alfa trial. Participants across both trials had an average ppFEV1 of 96·9%. Discontinuing treatment was non-inferior to continuing treatment with respect to the absolute 6-week change in ppFEV1 in both the hypertonic saline trial (-0·19% [95% CI -0·85 to 0·48] in the discontinuation group [n=133] vs 0·14% [-0·51 to 0·78] in the continuation group [n=140]; between-group difference -0·32% [-1·25 to 0·60]) and dornase alfa trial (0·18% [-0·38 to 0·74] in the discontinuation group [n=199] vs -0·16% [-0·73 to 0·41] in the continuation group [n=193]; between-group difference 0·35% [-0·45 to 1·14]), with consistent results in the intention-to-treat populations. In the hypertonic saline trial, 64 (35%) of 184 in the discontinuation group versus 44 (24%) of 186 participants in the continuation group and, in the dornase alfa trial, 89 (37%) of 240 in the discontinuation group versus 55 (23%) of 237 in the continuation group had at least one adverse event. INTERPRETATION In individuals with cystic fibrosis on ETI with relatively well preserved pulmonary function, discontinuing daily hypertonic saline or dornase alfa for 6 weeks did not result in clinically meaningful differences in pulmonary function when compared with continuing treatment.
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Terlizzi V, Parisi GF, Ferrari B, Castellani C, Manti S, Leonardi S, Taccetti G. Effect of Dornase Alfa on the Lung Clearance Index in Children with Cystic Fibrosis: A Lesson from a Case Series. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1625. [PMID: 36360353 PMCID: PMC9688561 DOI: 10.3390/children9111625] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 09/12/2023]
Abstract
BACKGROUND Dornase alfa (DNase) is the only mucus-degrading agent that has proven efficacy in cystic fibrosis (CF). Few studies have evaluated the effects of DNase on the lung clearance index (LCI). We report the experience of two CF centers in which LCI monitoring was used to evaluate the efficacy of DNase therapy. METHODS This is a prospective and observational study, evaluating the effects of DNase therapy on LCI values in three CF children followed at CF centers in Florence and Catania, Italy. In both centers, LCI was performed routinely, every 3-6 months, based on the clinical picture and severity of the lung disease. In this study, we evaluated the LCI before and after long-term DNase therapy. RESULTS DNase improved LCI values in the absence of respiratory exacerbations: in case n. 1 LCI decreased by 39% in 16 months (from 11.1 to 6.8); in case n. 2 by 20% in 12 months (from 9.3 to 7.4); in case n. 3 by 24% in 16 months (from 9.3 to 7.0). CONCLUSIONS This case series confirms the efficacy of DNase therapy in CF children, as demonstrated by the LCI reduction in treated patients. Furthermore, our results suggest that LCI is a sensitive marker of disease and can be used for the evaluation of response to treatment.
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Affiliation(s)
- Vito Terlizzi
- Cystic Fibrosis Regional Reference Center, Department of Paediatric Medicine, Meyer Children’s Hospital, 50139 Florence, Italy
| | - Giuseppe Fabio Parisi
- Pediatric Respiratory and Cystic Fibrosis Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, 95121 Catania, Italy
| | - Beatrice Ferrari
- Rehabilitation Unit, Meyer Children’s Hospital, 50139 Florence, Italy
| | - Chiara Castellani
- Rehabilitation Unit, Meyer Children’s Hospital, 50139 Florence, Italy
| | - Sara Manti
- Pediatric Respiratory and Cystic Fibrosis Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, 95121 Catania, Italy
- Pediatric Unit, Department of Human and Pediatric Pathology “Gaetano Barresi”, AOUP G. Martino, University of Messina, Via Consolare Valeria, 1, 98124 Messina, Italy
| | - Salvatore Leonardi
- Pediatric Respiratory and Cystic Fibrosis Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, 95121 Catania, Italy
| | - Giovanni Taccetti
- Cystic Fibrosis Regional Reference Center, Department of Paediatric Medicine, Meyer Children’s Hospital, 50139 Florence, Italy
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Terlizzi V, Castellani C, Taccetti G, Ferrari B. Dornase alfa in Cystic Fibrosis: indications, comparative studies and effects on lung clearance index. Ital J Pediatr 2022; 48:141. [PMID: 35927765 PMCID: PMC9351191 DOI: 10.1186/s13052-022-01331-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/26/2022] [Indexed: 11/28/2022] Open
Abstract
Cystic fibrosis (CF) is the most common inherited disease in Caucasian populations, affecting around 50,000 patients in Europe and 30,000 in United States. A mutation in CF trans-membrane conductance regulator (CFTR) gene changes a protein (a regulated chloride channel), which is expressed in many tissues. Defective CFTR results in reduced chloride secretion and an overage absorption of sodium across the epithelia, leading to thickened secretions in organs such as pancreas and lung. Gradually, there have been considerable improvements in the survival of people with CF, thanks to substantial changes in specialized CF care and the discovery of new CFTR modulators drugs. Nevertheless, lung disease remains the most common cause of death. For these reasons improvement of sputum clearance is a major therapeutic aim in CF. So far, symptomatic mucolytic therapy is mainly based on inhalation of dornase alfa, hypertonic saline or mannitol, in combination with physiotherapy. The major component of mucus in CF is pus including viscous material such as polymerized DNA derived from degraded neutrophils. Dornase alfa cleaves the DNA released from the neutrophils and reduces mucous viscosity, and further prevent airway infections and damage to the lung parenchyma. In this review we will summarize the current knowledge on dornase alfa in the treatment of CF lung disease, especially highlighting the positive effect on lung clearance index, a sensitive measure of ventilation inhomogeneity.
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Affiliation(s)
- Vito Terlizzi
- Department of Paediatric Medicine, Meyer Children's Hospital, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, 50139, Florence, Italy.
| | | | - Giovanni Taccetti
- Department of Paediatric Medicine, Meyer Children's Hospital, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, 50139, Florence, Italy
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