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Zhao B, Fine J, Ivanova A. Finding the best subgroup with differential treatment effect with multiple outcomes. Stat Med 2024; 43:2487-2500. [PMID: 38621856 DOI: 10.1002/sim.10083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/15/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024]
Abstract
Precision medicine aims to identify specific patient subgroups that may benefit the most from a particular treatment than the whole population. Existing definitions for the best subgroup in subgroup analysis are based on a single outcome and do not consider multiple outcomes; specifically, outcomes of different types. In this article, we introduce a definition for the best subgroup under a multiple-outcome setting with continuous, binary, and censored time-to-event outcomes. Our definition provides a trade-off between the subgroup size and the conditional average treatment effects (CATE) in the subgroup with respect to each of the outcomes while taking the relative contribution of the outcomes into account. We conduct simulations to illustrate the proposed definition. By examining the outcomes of urinary tract infection and renal scarring in the RIVUR clinical trial, we identify a subgroup of children that would benefit the most from long-term antimicrobial prophylaxis.
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Affiliation(s)
- Beibo Zhao
- Department of Biostatistics, CB #7420, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jason Fine
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Anastasia Ivanova
- Department of Biostatistics, CB #7420, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Wu TD, Diamant Z, Hanania NA. An Update on Patient-Reported Outcomes in Asthma. Chest 2024; 165:1049-1057. [PMID: 38365175 DOI: 10.1016/j.chest.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/18/2024] Open
Abstract
TOPIC IMPORTANCE Patient-reported outcomes (PROs) are information provided by patients on their condition, function, well-being, or experience. Instruments to quantify PROs, called patient-reported outcome measures (PROMs), allow standardized assessment of a unique dimension of health that cannot be measured physically. Herein, we discuss how to appraise PROMs critically and provide an update on their use in asthma clinical practice and research. REVIEW FINDINGS Asthma-specific PROMs have been developed to measure a wide array of disease characteristics, including symptoms, medication use, exacerbations, and impairments to emotional and physical function. Some PROMs also include spirometry or expand questions to overlap with rhinitis symptoms. Use of PROMs to understand asthma control is included in management guidelines, yet real-world evidence of their effectiveness in improving asthma care remains limited. These instruments may be less accurate in characterizing patients with poorly controlled asthma and have modest correlation with exacerbation risk. Two new PROMs are highlighted, the Asthma Impairment and Risk Questionnaire as an instrument to assess asthma control that incorporates domains related to exacerbation risk and impairment, and the CompEx as a composite of daily diary reporting combined with exacerbation events as an early efficacy signal for interventional trials. SUMMARY PROMs are fundamental to asthma assessment. Novel instruments may improve the detection of patients at risk for poor outcomes and shorten the drug discovery pipeline. However, urgent research is needed to understand their practical utility in clinical settings.
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Affiliation(s)
- Tianshi David Wu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston TX; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston TX.
| | - Zuzana Diamant
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen, The Netherlands; Department of Respiratory Medicine & Allergology, Skåne University Hospital, Lund, Sweden
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston TX
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3
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Perez-de-Llano L, Scelo G, Canonica GW, Chen W, Henley W, Larenas-Linnemann D, Peters MJ, Pfeffer PE, Tran TN, Ulrik CS, Popov TA, Sadatsafavi M, Hew M, Máspero J, Gibson PG, Christoff GC, Fitzgerald JM, Torres-Duque CA, Porsbjerg CM, Papadopoulos NG, Papaioannou AI, Heffler E, Iwanaga T, Al-Ahmad M, Kuna P, Fonseca JA, Al-Lehebi R, Rhee CK, Koh MS, Cosio BG, Perng Steve DW, Mahboub B, Menzies-Gow AN, Jackson DJ, Busby J, Heaney LG, Patel PH, Wang E, Wechsler ME, Altraja A, Lehtimäki L, Bourdin A, Bjermer L, Bulathsinhala L, Carter V, Murray R, Beastall A, Denton E, Price DB. Impact of pre-biologic impairment on meeting domain-specific biologic responder definitions in patients with severe asthma. Ann Allergy Asthma Immunol 2024; 132:610-622.e7. [PMID: 38151100 DOI: 10.1016/j.anai.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND There is little agreement on clinically useful criteria for identifying real-world responders to biologic treatments for asthma. OBJECTIVE To investigate the impact of pre-biologic impairment on meeting domain-specific biologic responder definitions in adults with severe asthma. METHODS This was a longitudinal, cohort study across 22 countries participating in the International Severe Asthma Registry (https://isaregistries.org/) between May 2017 and January 2023. Change in 4 asthma domains (exacerbation rate, asthma control, long-term oral corticosteroid [LTOCS] dose, and lung function) was assessed from biologic initiation to 1 year post-treatment (minimum 24 weeks). Pre- to post-biologic changes for responders and nonresponders were described along a categorical gradient for each domain derived from pre-biologic distributions (exacerbation rate: 0 to 6+/y; asthma control: well controlled to uncontrolled; LTOCS: 0 to >30 mg/d; percent-predicted forced expiratory volume in 1 second [ppFEV1]: <50% to ≥80%). RESULTS Percentage of biologic responders (ie, those with a category improvement pre- to post-biologic) varied by domain and increased with greater pre-biologic impairment, increasing from 70.2% to 90.0% for exacerbation rate, 46.3% to 52.3% for asthma control, 31.1% to 58.5% for LTOCS daily dose, and 35.8% to 50.6% for ppFEV1. The proportion of patients having improvement post-biologic tended to be greater for anti-IL-5/5R compared with for anti-IgE for exacerbation, asthma control, and ppFEV1 domains, irrespective of pre-biologic impairment. CONCLUSION Our results provide realistic outcome-specific post-biologic expectations for both physicians and patients, will be foundational to inform future work on a multidimensional approach to define and assess biologic responders and response, and may enhance appropriate patient selection for biologic therapies. TRIAL REGISTRATION The ISAR database has ethical approval from the Anonymous Data Ethics Protocols and Transparency (ADEPT) committee (ADEPT0218) and is registered with the European Union Electronic Register of Post-Authorization studies (ENCEPP/DSPP/23720). The study was designed, implemented, and reported in compliance with the European Network Centres for Pharmacoepidemiology and Pharmacovigilance (ENCEPP) Code of Conduct (EUPAS38288) and with all applicable local and international laws and regulation, and registered with ENCEPP (https://www.encepp.eu/encepp/viewResource.htm?id=38289). Governance was provided by ADEPT (registration number: ADEPT1220).
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Affiliation(s)
- Luis Perez-de-Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo, Spain
| | - Ghislaine Scelo
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care Global, Cambridge, United Kingdom
| | - G Walter Canonica
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Wenjia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - William Henley
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care Global, Cambridge, United Kingdom; Health Statistics Group, Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | | | - Matthew J Peters
- Department of Thoracic Medicine, Concord Hospital, Sydney, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Paul E Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, United Kingdom; Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Trung N Tran
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital - Hvidovre, Hvidovre, Denmark
| | - Todor A Popov
- University Hospital Sv. Ivan Rilski, Sofia, Bulgaria
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jorge Máspero
- Clinical Research for Allergy and Respiratory Medicine, CIDEA Foundation, Buenos Aires, Argentina; University Career of Specialists in Allergy and Clinical Immunology at the Buenos Aires University School of Medicine, Argentina
| | - Peter G Gibson
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia; Department of Respiratory and Sleep Medicine, Hunter Medical Research Institute, John Hunter Hospital, New Lambton Heights, Australia
| | | | - J Mark Fitzgerald
- Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Carlos A Torres-Duque
- CINEUMO, Respiratory Research Center, Fundación Neumológica Colombiana, Bogotá, Colombia; Universidad de La Sabana, Chia, Colombia
| | - Celeste M Porsbjerg
- Department of Respiratory Medicine and Infectious Diseases, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Nikolaos G Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, United Kingdom; Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - Andriana I Papaioannou
- 2nd Respiratory Medicine Department, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | | | - Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait City, Kuwait; Al-Rashed Allergy Center, Ministry of Health, Kuwait City, Kuwait
| | - Piotr Kuna
- Division of Internal Medicine Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - João A Fonseca
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Riyad Al-Lehebi
- Department of Pulmonology, King Fahad Medical City, Riyadh, Saudi Arabia; Alfaisal University, Riyadh, Saudi Arabia
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Borja G Cosio
- Son Espases University Hospital-IdISBa-Ciberes, Mallorca, Spain
| | - Diahn-Warng Perng Steve
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Bassam Mahboub
- Rashid Hospital, Dubai Health Authority (DHA), Dubai, United Arab Emirates
| | - Andrew N Menzies-Gow
- AstraZeneca, Cambridge, United Kingdom; Lung Division, Royal Brompton & Harefield Hospitals, London, United Kingdom
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's Hospital, King's College London, London, United Kingdom
| | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Pujan H Patel
- Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Eileen Wang
- Division of Allergy and Clinical Immunology, Department of Medicine, National Jewish Health and University of Colorado School of Medicine, Denver and Aurora, Colorado
| | - Michael E Wechsler
- NJH Cohen Family Asthma Institute, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Alan Altraja
- Department of Pulmonology, University of Tartu and Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Arnaud Bourdin
- PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Lakmini Bulathsinhala
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care Global, Cambridge, United Kingdom
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care Global, Cambridge, United Kingdom
| | - Ruth Murray
- Optimum Patient Care Global, Cambridge, United Kingdom
| | - Aaron Beastall
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care Global, Cambridge, United Kingdom
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care Global, Cambridge, United Kingdom; Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom.
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Bolton C, Harrison T, Lugogo N, Fuhlbrigge A, Hirsch I, Bengtsson T, Peterson S, Sidaway M, Garcia Gil E, Fagerås M, Da Silva CA. Use of CompEx in eosinophilic patients with severe, uncontrolled asthma on benralizumab. ERJ Open Res 2024; 10:01025-2023. [PMID: 38500798 PMCID: PMC10945385 DOI: 10.1183/23120541.01025-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 03/20/2024] Open
Abstract
Background CompEx Asthma, a composite end-point for asthma exacerbations, captures clinically relevant, diary-based acute worsening events (AWEs) (defined as deterioration in daily peak expiratory flow concurrent with deterioration in asthma symptoms and/or rescue therapy use) and severe exacerbations (SevEx) (defined by American Thoracic Society/European Respiratory Society guidelines). We hypothesised that CompEx and SevEx would show similar benralizumab treatment effects and correlations to blood eosinophil counts in patients with severe asthma. Methods This post hoc analysis of pooled 12-month data from two phase 3 studies included patients aged ≥16 years with severe, uncontrolled asthma who were randomised to benralizumab 30 mg or placebo. Annualised event rates were analysed using a negative binomial model. The impact of blood eosinophil count on treatment effect was assessed. Results Among patients with a blood eosinophil count ≥300 cells·µL-1 (n=913), benralizumab reduced the annualised event rate versus placebo for CompEx (1.57 versus 2.57; risk ratio 0.61, 95% CI 0.53-0.70, p<0.001), SevEx (0.94 versus 1.55; risk ratio 0.60, 95% CI 0.52-0.70, p<0.001) and AWE (0.92 versus 1.57; risk ratio 0.59, 95% CI 0.48-0.72, p<0.001), with greater treatment effects observed for higher blood eosinophil counts. In patients with blood eosinophil count ≥300 cells·µL-1, benralizumab was associated with shorter median event duration (CompEx: 10.5 days versus 17.0 days; SevEx: 10.0 days versus 15.0 days; AWE: 5.0 days versus 6.0 days). Conclusions Benralizumab reduced the risk of CompEx events with treatment effects similar to those for SevEx and AWEs across a range of blood eosinophil counts. Use of CompEx supports the evaluation of benralizumab and other novel drugs in clinical studies.
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Affiliation(s)
- Clare Bolton
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Tim Harrison
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
- Nottingham Respiratory NIHR BRC, University of Nottingham, Nottingham, UK
| | - Njira Lugogo
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Anne Fuhlbrigge
- Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ian Hirsch
- Late-stage Vaccine and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Thomas Bengtsson
- StatMind Statistical and Mathematical Modelling, Innovation and Design AB, Lund, Sweden
| | - Stefan Peterson
- StatMind Statistical and Mathematical Modelling, Innovation and Design AB, Lund, Sweden
| | - Martin Sidaway
- Early Respiratory and Immunology Clinical Development, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Malin Fagerås
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Carla A. Da Silva
- Early Respiratory and Immunology Clinical Development, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Howell I, Howell A, Ramakrishnan S, Bafadhel M, Pavord I. How have we measured trial outcomes of asthma attack treatment? A systematic review. ERJ Open Res 2024; 10:00660-2023. [PMID: 38410715 PMCID: PMC10895432 DOI: 10.1183/23120541.00660-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/21/2023] [Indexed: 02/28/2024] Open
Abstract
Background Asthma attacks are a common problem for people with asthma and are responsible for significant healthcare costs. There is interest in a precision medicine approach to treatment. However, the choice of trial outcome measures for asthma attack treatment is hampered by the absence of a consensus on suitability. We carried out a systematic review to understand the characteristics of outcome measures used in randomised controlled trials of asthma attack treatment. Have randomised controlled trials of asthma attack treatment measured outcomes that are useful to patients and healthcare providers? Methods The protocol was registered on PROSPERO (CRD42022311479). We searched for randomised controlled trials comparing treatments for adults with asthma attacks, published in English between 1972 and 2022 on MEDLINE, Embase and Cochrane Library databases. We recorded the outcome measures and study characteristics. Results We identified 208 eligible randomised controlled trials from 35 countries. Trials ranged from 12 to 1109 participants, with a median of 60. The most common settings were the emergency department (n=165) and hospital admission (n=33). Only 128 studies had primary and secondary outcomes defined clearly. In those that did, 73% of primary outcomes measured change in lung function or other physiological parameters over a short period (usually <24 h). Patient-reported and healthcare utilisation outcomes were the primary outcome in 27%. Conclusions Outcomes in randomised controlled trials of asthma attack treatment focus on short-term changes in lung function and may not capture patient-centred and economically important longer-term measures. More work is needed to investigate patient and other stakeholder preferences on core outcome sets.
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Affiliation(s)
- Imran Howell
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Aleksandra Howell
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sanjay Ramakrishnan
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia
| | - Mona Bafadhel
- King’s Centre of Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Ian Pavord
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Kappen J, Diamant Z, Agache I, Bonini M, Bousquet J, Canonica GW, Durham SR, Guibas GV, Hamelmann E, Jutel M, Papadopoulos NG, Roberts G, Shamji MH, Zieglmayer P, Gerth van Wijk R, Pfaar O. Standardization of clinical outcomes used in allergen immunotherapy in allergic asthma: An EAACI position paper. Allergy 2023; 78:2835-2850. [PMID: 37449468 DOI: 10.1111/all.15817] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION In allergic asthma patients, one of the more common phenotypes might benefit from allergen immunotherapy (AIT) as add-on intervention to pharmacological treatment. AIT is a treatment with disease-modifying modalities, the evidence for efficacy is based on controlled clinical trials following standardized endpoint measures. However, so far there is a lack of a consensus for asthma endpoints in AIT trials. The aim of a task force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) is evaluating several outcome measures for AIT in allergic asthma. METHODS The following domains of outcome measures in asthmatic patients have been evaluated for this position paper (PP): (i) exacerbation rate, (ii) lung function, (iii) ICS withdrawal, (iv) symptoms and rescue medication use, (v) questionnaires (PROMS), (vi) bronchial/nasal provocation, (vii) allergen exposure chambers (AEC) and (viii) biomarkers. RESULTS Exacerbation rate can be used as a reliable objective primary outcome; however, there is limited evidence due to different definitions of exacerbation. The time after ICS withdrawal to first exacerbation is considered a primary outcome measure. Besides, the advantages and disadvantages and clinical implications of further domains of asthma endpoints in AIT trials are elaborated in this PP. CONCLUSION This EAACI-PP aims to highlight important aspects of current asthma measures by critically evaluating their applicability for controlled trials of AIT.
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Affiliation(s)
- Jasper Kappen
- Department of Pulmonology, STZ Centre of Excellence for Asthma, COPD and Respiratory Allergy, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
| | - Zuzana Diamant
- Departmentt of Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium
- Department of Respiratory Medicine & Allergology, Institute for Clinical Science, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | | | - Matteo Bonini
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- Department of Cardiovascular and Thoracic Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Clinical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Jean Bousquet
- Charite Universitatsmedizin Berlin Campus Berlin Buch, MASK-air, Montpellier, France
| | - G Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic Humanitas University & Research Hospital-IRCCS, Milan, Italy
| | - Stephen R Durham
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - George V Guibas
- Department of Allergy and Clinical Immunology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- School of Biological Sciences, Medicine and Health, University of Manchester, Manchester, UK
| | - Eckard Hamelmann
- Children's Center Bethel, University Hospital Bielefeld, University Bielefeld, Bielefeld, Germany
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
| | | | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, UK
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Paediatric Allergy and Respiratory Medicine (MP803), Clinical & Experimental Sciences & Human Development in Health Academic Units University of Southampton Faculty of Medicine & University Hospital Southampton, Southampton, UK
| | - Mohamed H Shamji
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Petra Zieglmayer
- Karl Landsteiner University, Competence Center for Allergology and Immunology, Krems, Austria
| | - Roy Gerth van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
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Laurenzo SA, Townsend EA, Lane Starr NM, Wollet LJ, Castro M, Jarjour NN, Sorkness CA, Lee KE, Denlinger LC. Development and Dynamic Responsiveness of the Acute Asthma Exacerbation Survey in Patients With Moderate to Severe Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3425-3434.e4. [PMID: 37453571 PMCID: PMC11000541 DOI: 10.1016/j.jaip.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The recall periods and response scales of existing surveys of asthma control are poorly suited for studying acute exacerbations. OBJECTIVE To develop an instrument able to predict exacerbations after the onset of acute symptoms and with a recall window sufficiently short to study recovery. METHODS We developed the six-item Acute Asthma Exacerbation Survey (AAES). Data were collected at baseline, acute, and recovery visits within an established longitudinal protocol for participants with severe asthma. Participants scheduled acute study visits at the first sign of a cold. Nasal lavage samples and lung function measurements were also collected. The AAES data were analyzed using Cronbach α, Spearman correlations, and Kruskal-Wallace methods. We used logistic regression for predictors of bursts of oral corticosteroids (OCS). RESULTS Of 130 participants studied at baseline, 52 returned for an acute visit. The AAES scores were elevated at the acute visit and returned to baseline after recovery independently of respiratory virus detection. Cronbach α for the AAES was 0.853, 0.822, and 0.889 at the three respective visits. Compared with participants not needing burst OCS, those with exacerbations had higher acute AAES scores (16 [13.5-18] vs 11.5 [8.2-14], median [interquartile range]; P = .017) and a larger reduction from baseline in lung function. For each 3-point increase in AAES scores, the odds ratio for burst OCS use was 1.64 (95% CI, 1.04-2.57; P = .030). CONCLUSIONS The AAES is internally consistent and dynamically responsive during acute asthma exacerbations. Additional validation studies are warranted to support future trials and aid in clinical decision-making.
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Affiliation(s)
- Scott A Laurenzo
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Elizabeth A Townsend
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Nicole M Lane Starr
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Lori J Wollet
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Mario Castro
- Department of Internal Medicine, University of Kansas-Kansas City, Kansas City, Kan
| | - Nizar N Jarjour
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Christine A Sorkness
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Pharmacy Practice and Translational Research Division, University of Wisconsin School of Pharmacy, Madison, Wis
| | - Kristine E Lee
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Loren C Denlinger
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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8
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Khaleva E, Rattu A, Brightling C, Bush A, Bourdin A, Bossios A, Chung KF, Chaudhuri R, Coleman C, Djukanovic R, Dahlén SE, Exley A, Fleming L, Fowler SJ, Gupta A, Hamelmann E, Koppelman GH, Melén E, Mahler V, Seddon P, Singer F, Porsbjerg C, Ramiconi V, Rusconi F, Yasinska V, Roberts G. Definitions of non-response and response to biological therapy for severe asthma: a systematic review. ERJ Open Res 2023; 9:00444-2022. [PMID: 37143849 PMCID: PMC10152254 DOI: 10.1183/23120541.00444-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/06/2022] [Indexed: 01/27/2023] Open
Abstract
Background Biologics have proven efficacy for patients with severe asthma but there is lack of consensus on defining response. We systematically reviewed and appraised methodologically developed, defined and evaluated definitions of non-response and response to biologics for severe asthma. Methods We searched four bibliographic databases from inception to 15 March 2021. Two reviewers screened references, extracted data, and assessed methodological quality of development, measurement properties of outcome measures and definitions of response based on COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). A modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach and narrative synthesis were undertaken. Results 13 studies reported three composite outcome measures, three asthma symptoms measures, one asthma control measure and one quality of life measure. Only four measures were developed with patient input; none were composite measures. Studies utilised 17 definitions of response: 10 out of 17 (58.8%) were based on minimal clinically important difference (MCID) or minimal important difference (MID) and 16 out of 17 (94.1%) had high-quality evidence. Results were limited by poor methodology for the development process and incomplete reporting of psychometric properties. Most measures rated "very low" to "low" for quality of measurement properties and none met all quality standards. Conclusions This is the first review to synthesise evidence about definitions of response to biologics for severe asthma. While high-quality definitions are available, most are MCIDs or MIDs, which may be insufficient to justify continuation of biologics in terms of cost-effectiveness. There remains an unmet need for universally accepted, patient-centred, composite definitions to aid clinical decision making and comparability of responses to biologics.
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Affiliation(s)
- Ekaterina Khaleva
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anna Rattu
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Chris Brightling
- Institute for Lung Health, Leicester NIHR BRC, University of Leicester, UK
| | - Andrew Bush
- Centre for Paediatrics and Child Health and National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK
| | - Arnaud Bourdin
- PhyMedExp, University of Montpellier, Montpellier, France
| | - Apostolos Bossios
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Rekha Chaudhuri
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | | - Ratko Djukanovic
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sven-Erik Dahlén
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephen J. Fowler
- Faculty of Biology, Medicine and Health, School of Biological Sciences, Division of Infection, Immunity and Respiratory Medicine, University of Manchester, NIHR Manchester Biomedical Research Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Atul Gupta
- Department of Paediatric Respiratory Medicine, King's College Hospital, London, UK
| | - Eckard Hamelmann
- Children's Center Bethel, Department of Pediatrics, University Bielefeld, Bielefeld, Germany
| | - Gerard H. Koppelman
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Pulmonology and Pediatric Allergology, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
| | - Erik Melén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Vera Mahler
- Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Paul Seddon
- Respiratory Care, Royal Alexandra Children's Hospital, Brighton, UK
| | - Florian Singer
- Department of Respiratory Medicine, University Children's Hospital Zurich and Childhood Research Center, Zurich, Switzerland
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Celeste Porsbjerg
- Department of Respiratory Medicine, Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Valeria Ramiconi
- European Federation of Allergy and Airways Diseases Patients’ Associations, Brussels, Belgium
| | - Franca Rusconi
- Department of Mother and Child Health, Azienda USL Toscana Nord Ovest, Pisa, Italy
| | - Valentyna Yasinska
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Graham Roberts
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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9
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Siddiqui S, Haf Davies E, Afshar M, Denlinger LC. Clinical Trial Design Innovations for Precision Medicine in Asthma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1426:395-412. [PMID: 37464130 DOI: 10.1007/978-3-031-32259-4_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Severe asthma is a spectrum disorder with numerous subsets, many of which are defined by clinical history and a general predisposition for T2 inflammation. Most of the approved therapies for severe asthma have required clinical trial designs with population enrichment for exacerbation frequency and/or elevation of blood eosinophils. Moving beyond this framework will require trial designs that increase efficiency for studying nondominant subsets and continue to improve upon biomarker signatures. In addition to reviewing the current literature on biomarker-informed trials for severe asthma, this chapter will also review the advantages of master protocols and adaptive design methods for establishing the efficacy of new interventions in prospectively defined subsets of patients. The incorporation of methods that allow for data collection outside of traditional study visits at academic centers, called remote decentralized trial design, is a growing trend that may increase diversity in study participation and allow for enhanced resiliency during the COVID-19 pandemic. Finally, reaching the goals of precision medicine in asthma will require increased emphasis on effectiveness studies. Recent advances in real-world data utilization from electronic health records are also discussed with a view toward pragmatic trial designs that could also incorporate the evaluation of biomarker signatures.
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Affiliation(s)
- Salman Siddiqui
- National Heart and Lung Institute, Imperial College, London, England, UK
| | | | - Majid Afshar
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Loren C Denlinger
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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10
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Moss MH, Lugogo NL, Castro M, Hanania NA, Ludwig-Sengpiel A, Saralaya D, Dobek R, Ojanguren I, Vyshnyvetskyy I, Bruey JM, Osterhout R, Tompkins CA, Dittrich K, Raghupathi K, Ortega H. Results of a Phase 2b Trial With GB001, a Prostaglandin D2 Receptor 2 Antagonist, in Moderate to Severe Eosinophilic Asthma. Chest 2022; 162:297-308. [DOI: 10.1016/j.chest.2022.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 10/19/2022] Open
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11
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Gadkar K, Feigelman J, Sukumaran S, Rodrigo MC, Staton T, Cai F, Bauer RN, Choy DF, Stokes CL, Scheerens H, Ramanujan S. Integrated systems modeling of severe asthma: Exploration of IL-33/ST2 antagonism. CPT Pharmacometrics Syst Pharmacol 2022; 11:1268-1277. [PMID: 35857704 PMCID: PMC9469696 DOI: 10.1002/psp4.12842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/27/2022] [Accepted: 06/09/2022] [Indexed: 01/12/2023] Open
Abstract
Asthma is a complex, heterogeneous disease with a high unmet medical need, despite therapies targeting a multitude of pathways. The ability to quantitatively integrate preclinical and clinical data on these pathways could aid in the development and testing of novel targets and therapeutics. In this work, we develop a computational model of asthma biology, including key cell types and mediators, and create a virtual population capturing clinical heterogeneity. The simulated responses to therapies targeting IL-13, IL-4Rα, IL-5, IgE, and TSLP demonstrate agreement with clinical endpoints and biomarkers of type 2 (T2) inflammation, including blood eosinophils, FEV1, IgE, and FeNO. We use the model to explore the potential benefit of targeting the IL-33 pathway with anti-IL-33 and anti-ST2. Model predictions are compared with data on blood eosinophils, FeNO, and FEV1 from recent anti-IL-33 and anti-ST2 trials and used to interpret trial results based on pathway biology and pharmacology. Results of sensitivity analyses on the contributions of IL-33 to the predicted biomarker changes suggest that anti-ST2 therapy reduces circulating blood eosinophil levels primarily through its impact on eosinophil progenitor maturation and IL-5-dependent survival, and induces changes in FeNO and FEV1 through its effect on immune cells involved in T2 cytokine production. Finally, we also investigate the impact of ST2 genetics on the conferred benefit of anti-ST2. The model includes representation of a wide array of biologic mechanisms and interventions that will provide mechanistic insight and support clinical program design for a wide range of novel therapies during drug development.
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Affiliation(s)
- Kapil Gadkar
- Genentech, Inc., South San Francisco, California, USA.,Denali Therapeutics, Inc., South San Francisco, California, USA
| | | | - Siddharth Sukumaran
- Genentech, Inc., South San Francisco, California, USA.,Janssen, Inc., Spring House, Pennsylvania, USA
| | - Manoj C Rodrigo
- Genentech, Inc., South San Francisco, California, USA.,Stryker, Inc., Fremont, California, USA
| | - Tracy Staton
- Genentech, Inc., South San Francisco, California, USA
| | - Fang Cai
- Genentech, Inc., South San Francisco, California, USA.,AbbVie, Inc., South San Francisco, California, USA
| | | | - David F Choy
- Genentech, Inc., South San Francisco, California, USA
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12
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Georas SN, Wright RJ, Ivanova A, Israel E, LaVange LM, Akuthota P, Carr TF, Denlinger LC, Fajt ML, Kumar R, O'Neal WK, Phipatanakul W, Szefler SJ, Aronica MA, Bacharier LB, Burbank AJ, Castro M, Crotty Alexander L, Bamdad J, Cardet JC, Comhair SAA, Covar RA, DiMango EA, Erwin K, Erzurum SC, Fahy JV, Gaffin JM, Gaston B, Gerald LB, Hoffman EA, Holguin F, Jackson DJ, James J, Jarjour NN, Kenyon NJ, Khatri S, Kirwan JP, Kraft M, Krishnan JA, Liu AH, Liu MC, Marquis MA, Martinez F, Mey J, Moore WC, Moy JN, Ortega VE, Peden DB, Pennington E, Peters MC, Ross K, Sanchez M, Smith LJ, Sorkness RL, Wechsler ME, Wenzel SE, White SR, Zein J, Zeki AA, Noel P. The Precision Interventions for Severe and/or Exacerbation-Prone (PrecISE) Asthma Network: An overview of Network organization, procedures, and interventions. J Allergy Clin Immunol 2022; 149:488-516.e9. [PMID: 34848210 PMCID: PMC8821377 DOI: 10.1016/j.jaci.2021.10.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/24/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022]
Abstract
Asthma is a heterogeneous disease, with multiple underlying inflammatory pathways and structural airway abnormalities that impact disease persistence and severity. Recent progress has been made in developing targeted asthma therapeutics, especially for subjects with eosinophilic asthma. However, there is an unmet need for new approaches to treat patients with severe and exacerbation-prone asthma, who contribute disproportionately to disease burden. Extensive deep phenotyping has revealed the heterogeneous nature of severe asthma and identified distinct disease subtypes. A current challenge in the field is to translate new and emerging knowledge about different pathobiologic mechanisms in asthma into patient-specific therapies, with the ultimate goal of modifying the natural history of disease. Here, we describe the Precision Interventions for Severe and/or Exacerbation-Prone Asthma (PrecISE) Network, a groundbreaking collaborative effort of asthma researchers and biostatisticians from around the United States. The PrecISE Network was designed to conduct phase II/proof-of-concept clinical trials of precision interventions in the population with severe asthma, and is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Using an innovative adaptive platform trial design, the PrecISE Network will evaluate up to 6 interventions simultaneously in biomarker-defined subgroups of subjects. We review the development and organizational structure of the PrecISE Network, and choice of interventions being studied. We hope that the PrecISE Network will enhance our understanding of asthma subtypes and accelerate the development of therapeutics for severe asthma.
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Affiliation(s)
- Steve N Georas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, Rochester, NY.
| | | | - Anastasia Ivanova
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Elliot Israel
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Lisa M LaVange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Praveen Akuthota
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Merritt L Fajt
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | | | - Wanda K O'Neal
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | | | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Mark A Aronica
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Allison J Burbank
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Mo
| | - Laura Crotty Alexander
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Julie Bamdad
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Md
| | | | | | | | | | - Kim Erwin
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Ill
| | | | - John V Fahy
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | | | - Benjamin Gaston
- Wells Center for Pediatric Research, Indiana University, Indianapolis, Ind
| | - Lynn B Gerald
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Daniel J Jackson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - John James
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Nicholas J Kenyon
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Sumita Khatri
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - John P Kirwan
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, La
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Andrew H Liu
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Mark C Liu
- Pulmonary and Critical Care Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Md
| | - M Alison Marquis
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Fernando Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jacob Mey
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, La
| | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - James N Moy
- Rush University Medical Center, Chicago, Ill
| | - Victor E Ortega
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - David B Peden
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | | | - Michael C Peters
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Kristie Ross
- The Cleveland Clinic, Cleveland, Ohio; UH Rainbow Babies and Children's Hospitals, Cleveland, Ohio
| | - Maria Sanchez
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | | | - Ronald L Sorkness
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Michael E Wechsler
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Joe Zein
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Md
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13
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Leander J, Jirstrand M, Eriksson UG, Palmér R. A stochastic mixed effects model to assess treatment effects and fluctuations in home‐measured peak expiratory flow and the association with exacerbation risk in asthma. CPT Pharmacometrics Syst Pharmacol 2022; 11:212-224. [PMID: 34797036 PMCID: PMC8846634 DOI: 10.1002/psp4.12748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 10/20/2021] [Accepted: 11/08/2021] [Indexed: 11/07/2022] Open
Abstract
Home‐based measures of lung function, inflammation, symptoms, and medication use are frequently collected in respiratory clinical trials. However, new statistical approaches are needed to make better use of the information contained in these data‐rich variables. In this work, we use data from two phase III asthma clinical trials demonstrating the benefit of benralizumab treatment to develop a novel longitudinal mixed effects model of peak expiratory flow (PEF), a lung function measure easily captured at home using a hand‐held device. The model is based on an extension of the mixed effects modeling framework to incorporate stochastic differential equations and allows for quantification of several statistical properties of a patient's PEF data: the longitudinal trend, long‐term fluctuations, and day‐to‐day variability. These properties are compared between treatment groups and related to a patient's exacerbation risk using a repeated time‐to‐event model. The mixed effects model adequately described the observed data from the two clinical trials, and model parameters were accurately estimated. Benralizumab treatment was shown to improve a patient's average PEF level and reduce long‐term fluctuations. Both of these effects were shown to be associated with a lower exacerbation risk. The day‐to‐day variability was neither significantly affected by treatment nor associated with exacerbation risk. Our work shows the potential of a stochastic model‐based analysis of home‐based lung function measures to support better estimation and understanding of treatment effects and disease stability. The proposed analysis can serve as a complement to descriptive statistics of home‐based measures in the reporting of respiratory clinical trials.
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Affiliation(s)
- Jacob Leander
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D AstraZeneca Gothenburg Sweden
- Fraunhofer‐Chalmers Centre Chalmers Science Park Gothenburg Sweden
- Department of Mathematical Sciences Chalmers University of Technology and University of Gothenburg Gothenburg Sweden
| | - Mats Jirstrand
- Fraunhofer‐Chalmers Centre Chalmers Science Park Gothenburg Sweden
| | - Ulf G. Eriksson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D AstraZeneca Gothenburg Sweden
| | - Robert Palmér
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D AstraZeneca Gothenburg Sweden
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14
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Prothon S, Aurivillius M, Tehler U, Eriksson UG, Aggarwal A, Chen Y. Safety, Pharmacokinetics and Pharmacodynamics of the Selective Glucocorticoid Receptor Modulator Velsecorat (AZD7594) Following Inhalation in Healthy Volunteers. Drug Des Devel Ther 2022; 16:485-497. [PMID: 35264846 PMCID: PMC8901234 DOI: 10.2147/dddt.s334960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/06/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Velsecorat (AZD7594) is a non-steroidal, selective, glucocorticoid receptor modulator (SGRM), being developed for the treatment of asthma. This article reports the initial, first-in-human, single and repeat dose-escalating study in healthy male volunteers. Methods The study comprised two parts, a single ascending dose part (n=47) and a multiple ascending dose part (n=26). Inhaled velsecorat was administered by nebulization as one single dose in the first part of the study and as a single dose with subsequent multiple daily doses (day 5–16) for 12 days once daily in the second part of the study. At each dose level, participants were randomized to velsecorat (n=6) or placebo (n=2/3). The safety, pharmacokinetics (PK) and pharmacodynamics (PD) of velsecorat were evaluated. Results Inhaled velsecorat was safe and well tolerated up to and including the highest dose tested (1872 µg). Plasma exposure suggested dose proportional PK. The terminal half-life following repeated dosing was 25–31 hours and steady state conditions for velsecorat in plasma were generally reached within 4 doses. The accumulation ratio was low (≤2), and data did not indicate any time-dependent PK. There were dose-related effects on 24-hour plasma cortisol, plasma cortisol after ACTH stimulation and osteocalcin, systemic PD markers of glucocorticoid activity. There were no effects on other biomarkers tested (DHEA-S and 4βOH-cholesterol). Conclusion The early clinical evaluation of inhaled velsecorat suggests that this novel SGRM is well tolerated in the dose range investigated. It shows dose proportional plasma exposure, low accumulation, and has dose-dependent effects on markers of glucocorticoid activity.
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Affiliation(s)
- Susanne Prothon
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
- Correspondence: Susanne Prothon, Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Pepparedsleden 1, Mölndal, Gothenburg, 431 83, Sweden, Email
| | - Magnus Aurivillius
- Late Stage Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulrika Tehler
- Advanced Drug Delivery, Pharmaceutical Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulf G Eriksson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Ajay Aggarwal
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Boston, MA, USA
| | - Yingxue Chen
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Boston, MA, USA
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15
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Svensson RJ, Ribbing J, Kotani N, Dolton M, Vadhavkar S, Cheung D, Staton T, Choy DF, Putnam W, Jin J, Budha N, Karlsson MO, Quartino A, Zhu R. Population repeated time-to-event analysis of exacerbations in asthma patients: A novel approach for predicting asthma exacerbations based on biomarkers, spirometry, and diaries/questionnaires. CPT Pharmacometrics Syst Pharmacol 2021; 10:1221-1235. [PMID: 34346168 PMCID: PMC8520748 DOI: 10.1002/psp4.12690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 11/07/2022] Open
Abstract
Identification of covariates, including biomarkers, spirometry, and diaries/questionnaires, that predict asthma exacerbations would allow better clinical predictions, shorter phase II trials and inform decisions on phase III design, and/or initiation (go/no-go). The objective of this work was to characterize asthma-exacerbation hazard as a function of baseline and time-varying covariates. A repeated time-to-event (RTTE) model for exacerbations was developed using data from a 52-week phase IIb trial, including 502 patients with asthma randomized to placebo or 70 mg, 210 mg, or 490 mg astegolimab every 4 weeks. Covariate analysis was performed for 20 baseline covariates using the full random effects modeling approach, followed by time-varying covariate analysis of nine covariates using the stepwise covariate model (SCM) building procedure. Following the SCM, an astegolimab treatment effect was explored. Diary-based symptom score (difference in objective function value [dOFV] of -83.7) and rescue medication use (dOFV = -33.5), and forced expiratory volume in 1 s (dOFV = -14.9) were identified as significant time-varying covariates. Of note, time-varying covariates become more useful with more frequent measurements, which should favor the daily diary scores over others. The most influential baseline covariates were exacerbation history and diary-based symptom score (i.e., symptom score was important as both time-varying and baseline covariate). A (nonsignificant) astegolimab treatment effect was included in the final model because the limited data set did not allow concluding the remaining effect size as irrelevant. Without time-varying covariates, the treatment effect was statistically significant (p < 0.01). This work demonstrated the utility of a population RTTE approach to characterize exacerbation hazard in patients with severe asthma.
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Affiliation(s)
| | | | - Naoki Kotani
- GenentechSouth San FranciscoCaliforniaUSA
- Chugai PharmaceuticalTokyoJapan
| | | | | | | | | | | | | | - Jin Jin
- GenentechSouth San FranciscoCaliforniaUSA
| | | | - Mats O. Karlsson
- PharmetheusUppsalaSweden
- Department of PharmacyUppsala UniversityUppsalaSweden
| | | | - Rui Zhu
- GenentechSouth San FranciscoCaliforniaUSA
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Israel E, Denlinger LC, Bacharier LB, LaVange LM, Moore WC, Peters MC, Georas SN, Wright RJ, Mauger DT, Noel P, Akuthota P, Bach J, Bleecker ER, Cardet JC, Carr TF, Castro M, Cinelli A, Comhair SAA, Covar RA, Alexander LC, DiMango EA, Erzurum SC, Fahy JV, Fajt ML, Gaston BM, Hoffman EA, Holguin F, Jackson DJ, Jain S, Jarjour NN, Ji Y, Kenyon NJ, Kosorok MR, Kraft M, Krishnan JA, Kumar R, Liu AH, Liu MC, Ly NP, Marquis MA, Martinez FD, Moy JN, O'Neal WK, Ortega VE, Peden DB, Phipatanakul W, Ross K, Smith LJ, Szefler SJ, Teague WG, Tulchinsky AF, Vijayanand P, Wechsler ME, Wenzel SE, White SR, Zeki AA, Ivanova A. PrecISE: Precision Medicine in Severe Asthma: An adaptive platform trial with biomarker ascertainment. J Allergy Clin Immunol 2021; 147:1594-1601. [PMID: 33667479 PMCID: PMC8113113 DOI: 10.1016/j.jaci.2021.01.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
Severe asthma accounts for almost half the cost associated with asthma. Severe asthma is driven by heterogeneous molecular mechanisms. Conventional clinical trial design often lacks the power and efficiency to target subgroups with specific pathobiological mechanisms. Furthermore, the validation and approval of new asthma therapies is a lengthy process. A large proportion of that time is taken by clinical trials to validate asthma interventions. The National Institutes of Health Precision Medicine in Severe and/or Exacerbation Prone Asthma (PrecISE) program was established with the goal of designing and executing a trial that uses adaptive design techniques to rapidly evaluate novel interventions in biomarker-defined subgroups of severe asthma, while seeking to refine these biomarker subgroups, and to identify early markers of response to therapy. The novel trial design is an adaptive platform trial conducted under a single master protocol that incorporates precision medicine components. Furthermore, it includes innovative applications of futility analysis, cross-over design with use of shared placebo groups, and early futility analysis to permit more rapid identification of effective interventions. The development and rationale behind the study design are described. The interventions chosen for the initial investigation and the criteria used to identify these interventions are enumerated. The biomarker-based adaptive design and analytic scheme are detailed as well as special considerations involved in the final trial design.
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Affiliation(s)
- Elliot Israel
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Lisa M LaVange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael C Peters
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Steve N Georas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - David T Mauger
- Pennsylvania State University School of Medicine, Hershey, Pa
| | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Praveen Akuthota
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Julia Bach
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Eugene R Bleecker
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | | | - Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Kan
| | | | | | | | - Laura Crotty Alexander
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | | | | | - John V Fahy
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Merritt L Fajt
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Benjamin M Gaston
- Wells Center for Pediatric Research, Indiana University, Indianapolis, Ind
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Daniel J Jackson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Sonia Jain
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Yuan Ji
- Department of Health Studies, University of Chicago, Chicago, Ill
| | - Nicholas J Kenyon
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Michael R Kosorok
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | | | - Andrew H Liu
- University of Colorado School of Medicine, Aurora, Colo; Children's Hospital Colorado, Aurora, Colo
| | - Mark C Liu
- Pulmonary and Critical Care Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Md
| | - Ngoc P Ly
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - M Alison Marquis
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - James N Moy
- Rush University Medical Center, Chicago, Ill
| | - Wanda K O'Neal
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | - Victor E Ortega
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - David B Peden
- Marsico Lung Institute, UNC CF Research Center, University of North Carolina, Chapel Hill, NC
| | | | - Kristie Ross
- UH Rainbow Babies and Children's Hospitals, Cleveland, Ohio
| | | | - Stanley J Szefler
- University of Colorado School of Medicine, Aurora, Colo; Children's Hospital Colorado, Aurora, Colo
| | - W Gerald Teague
- University of Virginia School of Medicine, Charlottesville, Va
| | | | | | - Michael E Wechsler
- National Jewish Health, Denver, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Anastasia Ivanova
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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Kelsen SG, Agache IO, Soong W, Israel E, Chupp GL, Cheung DS, Theess W, Yang X, Staton TL, Choy DF, Fong A, Dash A, Dolton M, Pappu R, Brightling CE. Astegolimab (anti-ST2) efficacy and safety in adults with severe asthma: A randomized clinical trial. J Allergy Clin Immunol 2021; 148:790-798. [PMID: 33872652 DOI: 10.1016/j.jaci.2021.03.044] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/20/2021] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The IL-33/ST2 pathway is linked with asthma susceptibility. Inhaled allergens, pollutants, and respiratory viruses, which trigger asthma exacerbations, induce release of IL-33, an epithelial-derived "alarmin." Astegolimab, a human IgG2 mAb, selectively inhibits the IL-33 receptor, ST2. Approved biologic therapies for severe asthma mainly benefit patients with elevated blood eosinophils (type 2-high), but limited options are available for patients with low blood eosinophils (type 2-low). Inhibiting IL-33 signaling may target pathogenic pathways in a wider spectrum of asthmatics. OBJECTIVES This study evaluated astegolimab efficacy and safety in patients with severe asthma. METHODS This double-blind, placebo-controlled, dose-ranging study (ZENYATTA [A Study to Assess the Efficacy and Safety of MSTT1041A in Participants With Uncontrolled Severe Asthma]) randomized 502 adults with severe asthma to subcutaneous placebo or 70-mg, 210-mg, or 490-mg doses of astegolimab every 4 weeks. The primary endpoint was the annualized asthma exacerbation rate (AER) at week 54. Enrollment caps ensured ∼30 patients who were eosinophil-high (≥300 cells/μL) and ∼95 patients who were eosinophil-low (<300 cells/μL) per arm. RESULTS Overall, adjusted AER reductions relative to placebo were 43% (P = .005), 22% (P = .18), and 37% (P = .01) for 490-mg, 210-mg, and 70-mg doses of astegolimab, respectively. Adjusted AER reductions for patients who were eosinophil-low were comparable to reductions in the overall population: 54% (P = .002), 14% (P = .48), and 35% (P = .05) for 490-mg, 210-mg, and 70-mg doses of astegolimab. Adverse events were similar in astegolimab- and placebo-treated groups. CONCLUSIONS Astegolimab reduced AER in a broad population of patients, including those who were eosinophil-low, with inadequately controlled, severe asthma. Astegolimab was safe and well tolerated.
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Affiliation(s)
- Steven G Kelsen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Ioana O Agache
- Allergy and Clinical Immunology, Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Weily Soong
- Alabama Allergy and Asthma Center and Clinical Research Center of Alabama, Birmingham, Ala
| | - Elliot Israel
- Divisions of Pulmonary and Critical Care Medicine and Allergy and Immunology, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass
| | - Geoffrey L Chupp
- Division of Pulmonary and Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Conn
| | | | | | | | | | | | - Alice Fong
- Genentech, Inc., South San Francisco, Calif
| | - Ajit Dash
- Genentech, Inc., South San Francisco, Calif
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18
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Tejwani V, Chang HY, Tran AP, Naber JA, Gutzwiller FS, Winders TA, Khurana S, Sumino K, Mosnaim G, Moloney RM. A multistakeholder Delphi consensus core outcome set for clinical trials in moderate-to-severe asthma (coreASTHMA). Ann Allergy Asthma Immunol 2021; 127:116-122.e7. [PMID: 33781936 DOI: 10.1016/j.anai.2021.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/09/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Treatments for long-term control of asthma have improved and include a promising but expensive class of biologic therapies. However, the clinical trials evaluating these and other novel treatments have used a variety of different outcomes to evaluate efficacy. The evolution of asthma care calls for a re-examination of outcomes that are most important to patients and other stakeholders. OBJECTIVE To develop a core set of outcomes to be measured in phase 3 and phase 4 clinical drug trials in patients with moderate-to-severe asthma. METHODS We used a robust and in-depth multistakeholder consensus process bringing together patients, clinicians, regulators, payers, health technology assessors, researchers, and product developers to reach consensus on outcomes. We used a modified Delphi method to reach consensus, an approach adapted from the Core Outcome Measures in Effectiveness Trials Initiative aligned with contemporary methodological standards for core outcome set development. RESULTS The following outcomes were included in the final core set: severe asthma exacerbation, change in asthma control, asthma-specific or severe asthma-specific quality of life, asthma-specific hospital stay (ie, >24-hour stays at any level of care) or admission, and asthma-specific emergency department visit. CONCLUSION These 5 outcomes represent a minimum set of core outcomes for use in phase 3 and phase 4 clinical drug trials in moderate-to-severe asthma. Consistent collection of these outcomes as minimum, independent of whether additional heterogeneous primary or secondary outcomes are included, will allow for meaningful comparisons of the effect of asthma therapies across clinical trials.
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Affiliation(s)
- Vickram Tejwani
- Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland.
| | | | - Annie P Tran
- Center for Medical Technology Policy, Baltimore, Maryland
| | | | | | | | - Sandhya Khurana
- Pulmonary and Critical Care Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Kaharu Sumino
- Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Giselle Mosnaim
- Pulmonary, Allergy and Critical Care, NorthShore University HealthSystem, Evanston, Illinois
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McCrae C, Olsson M, Gustafson P, Malmgren A, Aurell M, Fagerås M, Da Silva CA, Cavallin A, Paraskos J, Karlsson K, Wingren C, Monk P, Marsden R, Harrison T. INEXAS: A Phase 2 Randomized Trial of On-demand Inhaled Interferon Beta-1a in Severe Asthmatics. Clin Exp Allergy 2021; 51:273-283. [PMID: 33091192 PMCID: PMC7984268 DOI: 10.1111/cea.13765] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/18/2020] [Accepted: 10/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Upper respiratory tract infections (URTIs) are important triggers for asthma exacerbations. We hypothesized that inhalation of the anti-viral cytokine, interferon (IFN)-β, during URTI, could prevent these exacerbations. OBJECTIVE To evaluate the efficacy of on-demand inhaled IFN-β1a (AZD9412) to prevent severe asthma exacerbations following symptomatic URTI. METHODS This was a randomized, double-blind, placebo-controlled trial in which patients with severe asthma (GINA 4-5; n = 121) reporting URTI symptoms were randomized to 14 days of once-daily nebulized AZD9412 or placebo. The primary endpoint was severe exacerbations during treatment. Secondary endpoints included 6-item asthma control questionnaire (ACQ-6) and lung function. Exploratory biomarkers included IFN-response markers in serum and sputum, blood leucocyte counts and serum inflammatory cytokines. RESULTS Following a pre-planned interim analysis, the trial was terminated early due to an unexpectedly low exacerbation rate. Asthma worsenings were generally mild and tended to peak at randomization, possibly contributing to the lack of benefit of AZD9412 on other asthma endpoints. Numerically, AZD9412 did not reduce severe exacerbation rate, ACQ-6, asthma symptom scores or reliever medication use. AZD9412 improved lung function (morning peak expiratory flow; mPEF) by 19.7 L/min. Exploratory post hoc analyses indicated a greater mPEF improvement by AZD9412 in patients with high blood eosinophils (>0.3 × 109 /L) at screening and low serum interleukin-18 relative change at pre-treatment baseline. Pharmacodynamic effect of AZD9412 was confirmed using IFN-response markers. CONCLUSIONS & CLINICAL RELEVANCE Colds did not have the impact on asthma patients that was expected and, due to the low exacerbation rate, the trial was stopped early. On-demand AZD9412 treatment did not numerically reduce the number of exacerbations, but did attenuate URTI-induced worsening of mPEF. Severe asthma patients with high blood eosinophils or low serum interleukin-18 response are potential subgroups for further investigation of inhaled IFN-β1a.
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Affiliation(s)
- Christopher McCrae
- Translational Science and Experimental Medicine, Research and Early DevelopmentRespiratory & Immunology, BioPharmaceuticals R&DAstraZenecaGaithersburgMarylandUSA
- Krefting Research CentreDepartment of Internal Medicine and Clinical NutritionInstitute of MedicineUniversity of GothenburgGothenburgSweden
| | - Marita Olsson
- Early Biometrics and Statistical InnovationData Science and AI, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Per Gustafson
- BioPharmaceutical MedicalAstraZenecaGothenburgSweden
| | - Anna Malmgren
- Early Respiratory & Immunology Projects DepartmentBioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Malin Aurell
- Early Respiratory & Immunology Clinical DevelopmentBioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Malin Fagerås
- BioPharmaceutical MedicalAstraZenecaGothenburgSweden
| | - Carla A. Da Silva
- Early Respiratory & Immunology Clinical DevelopmentBioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Anders Cavallin
- Translational Science and Experimental MedicineEarly Cardiovascular, Renal and Metabolism (CVRM)BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Jonathan Paraskos
- Point of Care Diagnostics, Precision MedicineOncology R&DAstraZenecaCambridgeUK
| | - Karin Karlsson
- Translational Science and Experimental MedicineEarly Cardiovascular, Renal and Metabolism (CVRM)BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Cecilia Wingren
- Translational Science and Experimental Medicine, Research and Early DevelopmentRespiratory & Immunology, BioPharmaceuticals R&DAstraZenecaGaithersburgMarylandUSA
| | - Phillip Monk
- Synairgen Research LtdSouthampton University HospitalSouthamptonUK
| | - Richard Marsden
- Synairgen Research LtdSouthampton University HospitalSouthamptonUK
| | - Tim Harrison
- Nottingham NIHR Biomedical Research CentreUniversity of NottinghamNottingham City HospitalNottinghamUK
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20
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Ivanova A, Israel E, LaVange LM, Peters MC, Denlinger LC, Moore WC, Bacharier LB, Marquis MA, Gotman NM, Kosorok MR, Tomlinson C, Mauger DT, Georas SN, Wright RJ, Noel P, Rosner GL, Akuthota P, Billheimer D, Bleecker ER, Cardet JC, Castro M, DiMango EA, Erzurum SC, Fahy JV, Fajt ML, Gaston BM, Holguin F, Jain S, Kenyon NJ, Krishnan JA, Kraft M, Kumar R, Liu MC, Ly NP, Moy JN, Phipatanakul W, Ross K, Smith LJ, Szefler SJ, Teague WG, Wechsler ME, Wenzel SE, White SR. The precision interventions for severe and/or exacerbation-prone asthma (PrecISE) adaptive platform trial: statistical considerations. J Biopharm Stat 2020; 30:1026-1037. [PMID: 32941098 PMCID: PMC7954787 DOI: 10.1080/10543406.2020.1821705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 12/24/2022]
Abstract
The Precision Interventions for Severe and/or Exacerbation-prone Asthma (PrecISE) study is an adaptive platform trial designed to investigate novel interventions to severe asthma. The study is conducted under a master protocol and utilizes a crossover design with each participant receiving up to five interventions and at least one placebo. Treatment assignments are based on the patients' biomarker profiles and precision health methods are incorporated into the interim and final analyses. We describe key elements of the PrecISE study including the multistage adaptive enrichment strategy, early stopping of an intervention for futility, power calculations, and the primary analysis strategy.
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Affiliation(s)
| | - Elliot Israel
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD
| | | | - Praveen Akuthota
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | - Dean Billheimer
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | | | | | | | | | | | | | - Merritt L. Fajt
- Wells Center for Pediatric Research, Indiana University, Indianapolis
| | | | | | | | | | - Jerry A. Krishnan
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | | | | | | | - Ngoc P. Ly
- Rush University Medical Center, Chicago, IL
| | - James N. Moy
- Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Wanda Phipatanakul
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Kristie Ross
- UH Rainbow Babies and Children’s Hospitals, Cleveland, OH
| | | | - Stanley J. Szefler
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | | | | | - Sally E. Wenzel
- National Jewish Health, Denver, CO, and University of Colorado School of Medicine, Aurora, CO
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21
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Jauhiainen A, Scheepers LEJM, Fuhlbrigge AL, Harrison T, Zangrilli J, Garcia Gil E, Gustafson P, Fagerås M, Da Silva CA. Impact of season and geography on CompEx Asthma: a composite end-point for exacerbations. ERJ Open Res 2020; 6:00246-2020. [PMID: 33123561 PMCID: PMC7569167 DOI: 10.1183/23120541.00246-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/21/2020] [Indexed: 11/22/2022] Open
Abstract
Background CompEx Asthma, a novel composite end-point combining severe exacerbations (SevEx) with asthma-worsening events, was recently developed. Further characterisation of CompEx Asthma is needed to illustrate the applicability of this end-point. The objective was to evaluate CompEx Asthma as a rate end-point to determine how seasonal and geographical factors impact this novel outcome. Methods Seven 24–56-week randomised controlled trials of budesonide/formoterol (BUD/FORM) and benralizumab were analysed. Annualised event rates (AERs) and treatment effects (hazard ratio (HR)) were analysed with Poisson and Andersen–Gill models, respectively. Seasonality was analysed by month and five geographical regions were evaluated. Results The studies included 10 815 patients (63% female, mean age 42–49 years). CompEx Asthma AER mirrored seasonal variations in SevEx AER. CompEx Asthma AERs were higher versus SevEx in BUD/FORM and benralizumab trials (range 2.7–4.5-fold and 1.3–2.0-fold increase, respectively) and were less variable versus SevEx between regions (ratios of greatest:smallest AERs: 1.36 for CompEx versus 2.28 for SevEx (BUD/FORM); 1.81 for CompEx versus 2.22 for SevEx (benralizumab)). Treatment effects for CompEx Asthma and SevEx were generally similar across regions and months. However, in Eastern Europe, where SevEx rates were lowest, treatment effect was greater with CompEx Asthma versus SevEx, reaching statistical significance in the benralizumab studies (HR (95% CI): 0.67 (0.53–0.85) versus 0.87 (0.65–1.15)). Conclusion This study confirmed the reliability of CompEx Asthma as a rate end-point and allowed detection of variations in seasonal SevEx rates, reduction of variation in rates across regions and potential greater sensitivity to treatment effects. CompEx Asthma is a valid end-point that reflects the treatment efficacy observed on SevEx when studying recurrent events and may enable smaller, 3-month clinical trials factoring in seasonal variationhttps://bit.ly/3jPI894
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Affiliation(s)
- Alexandra Jauhiainen
- BioPharma Early Biometrics and Statistical Innovation, Data Science & AI, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden.,Shared first authors
| | - Lieke E J M Scheepers
- BioPharma Early Biometrics and Statistical Innovation, Data Science & AI, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden.,Shared first authors
| | - Anne L Fuhlbrigge
- Pulmonary Sciences and Critical Care, Dept of Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Tim Harrison
- Nottingham NIHR Biomedical Research Centre, Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - James Zangrilli
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, USA
| | | | - Per Gustafson
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Malin Fagerås
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Carla A Da Silva
- Early Respiratory and Immunology Clinical Development, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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22
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Adibi A, Sin DD, Safari A, Johnson KM, Aaron SD, FitzGerald JM, Sadatsafavi M. The Acute COPD Exacerbation Prediction Tool (ACCEPT): a modelling study. THE LANCET. RESPIRATORY MEDICINE 2020; 8:1013-1021. [PMID: 32178776 DOI: 10.1016/s2213-2600(19)30397-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Accurate prediction of exacerbation risk enables personalised care for patients with chronic obstructive pulmonary disease (COPD). We developed and validated a generalisable model to predict individualised rate and severity of COPD exacerbations. METHODS In this risk modelling study, we pooled data from three COPD trials on patients with a history of exacerbations. We developed a mixed-effect model to predict exacerbations over 1 year. Severe exacerbations were those requiring inpatient care. Predictors were history of exacerbations, age, sex, body-mass index, smoking status, domiciliary oxygen therapy, lung function, symptom burden, and current medication use. Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE), a multicentre cohort study, was used for external validation. RESULTS The development dataset included 2380 patients, 1373 (58%) of whom were men. Mean age was 64·7 years (SD 8·8). Mean exacerbation rate was 1·42 events per year and 0·29 events per year were severe. When validated against all patients with COPD in ECLIPSE (mean exacerbation rate was 1·20 events per year, 0·27 events per year were severe), the area-under-curve (AUC) was 0·81 (95% CI 0·79-0·83) for at least two exacerbations and 0·77 (95% CI 0·74-0·80) for at least one severe exacerbation. Predicted exacerbation and observed exacerbation rates were similar (1·31 events per year for all exacerbations and 0·25 events per year for severe exacerbations vs 1·20 events per year and 0·27 events per year). In ECLIPSE, in patients with previous exacerbation history (mean exacerbation rate was 1·82 events per year, 0·40 events per year were severe), AUC was 0·73 (95% CI 0·70-0·76) for two or more exacerbations and 0·74 (95% CI 0·70-0·78) for at least one severe exacerbation. Calibration was accurate for severe exacerbations (predicted 0·37 events per year vs observed 0·40 events per year) and all exacerbations (predicted 1·80 events per year vs observed 1·82 events per year). INTERPRETATION This model can be used as a decision tool to personalise COPD treatment and prevent exacerbations. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Amin Adibi
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Don D Sin
- Division of Respiratory Medicine, Department of Medicine, The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Abdollah Safari
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Kate M Johnson
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada; Institute for Heart and Lung Health, Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada
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23
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COPDCompEx: A novel composite endpoint for COPD exacerbations to enable faster clinical development. Respir Med 2020; 173:106175. [PMID: 33032168 DOI: 10.1016/j.rmed.2020.106175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Frequency of moderate and severe chronic obstructive pulmonary disease exacerbations is an important endpoint in clinical trials, but makes them large and lengthy when powered to evaluate it. We aimed to develop a composite endpoint (COPDCompEx) that could predict treatment effect on exacerbations, enabling the design of shorter early phase clinical trials requiring fewer patients. METHODS In this post hoc analysis, data from 20 randomized controlled trials were used to develop and test COPDCompEx. Diary events were tested against predefined threshold values for peak expiratory flow, reliever medication use, and symptoms. A COPDCompEx event was defined as first occurrence of a diary event, a moderate or severe exacerbation, or a study dropout. Ratios of event frequency, treatment effect and future trial sample size were compared between COPDCompEx and moderate and severe exacerbations. FINDINGS At 3 months, the proportion of patients experiencing COPDCompEx events increased over 3-fold versus exacerbations alone. All components contributed to COPDCompEx event rate. Treatment effects at 3 months were closely matched between COPDCompEx and exacerbations, and the large net gain in power substantially reduced the required sample size. INTERPRETATION COPDCompEx may be used to predict treatment effect on moderate and severe exacerbations of chronic obstructive pulmonary disease. This may enable the design of shorter Phase 2 clinical trials requiring fewer patients when compared with current exacerbation studies, with exacerbations as a key Phase 3 endpoint. This would, therefore, allow more efficient decision-making with reduced burden and risk to study participants.
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Martin MJ, Beasley R, Harrison TW. Towards a personalised treatment approach for asthma attacks. Thorax 2020; 75:1119-1129. [PMID: 32839286 DOI: 10.1136/thoraxjnl-2020-214692] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 12/16/2022]
Abstract
Asthma attacks (exacerbations) are common, accounting for over 90 000 UK hospital admissions per annum. They kill nearly 1500 people per year in the UK, have significant associated direct and indirect costs and lead to accelerated and permanent loss of lung function. The recognition of asthma as a heterogeneous condition with multiple phenotypes has revolutionised the approach to the long-term management of the condition, with greater emphasis on personalised treatment and the introduction of the treatable traits concept. In contrast asthma attacks are poorly defined and understood and our treatment approach consists of bronchodilators and systemic corticosteroids. This review aims to explore the current limitations in the description, assessment and management of asthma attacks. We will outline the risk factors for attacks, strategies to modify this risk and describe the recognised characteristics of attacks as a first step towards the development of an approach for phenotyping and personalising the treatment of these critically important events. By doing this, we hope to gradually improve asthma attack treatment and reduce the adverse effects associated with recurrent courses of corticosteroids.
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Affiliation(s)
- Matthew J Martin
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Tim W Harrison
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
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Harrison T, Pavord ID, Chalmers JD, Whelan G, Fagerås M, Rutgersson A, Belton L, Siddiqui S, Gustafson P. Variability in airway inflammation, symptoms, lung function and reliever use in asthma: anti-inflammatory reliever hypothesis and STIFLE study design. ERJ Open Res 2020; 6:00333-2019. [PMID: 32550224 PMCID: PMC7276524 DOI: 10.1183/23120541.00333-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/24/2020] [Indexed: 11/05/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease. Increase in airway inflammation is hypothesised to contribute to worsening of asthma symptoms and deterioration in lung function, resulting in the use of reliever medication. Short-acting β2-agonists only treat the symptoms, whereas an anti-inflammatory reliever is believed to treat both symptoms and the underlying inflammation, thereby arresting the progression to an exacerbation. As-needed budesonide/formoterol as an anti-inflammatory reliever reduces the risk of severe exacerbations. However, supporting mechanistic evidence has not yet been described, specifically the temporal dynamics of parameters including airway inflammation, over time and during asthma worsening. The STIFLE study aims to characterise daily variability in airway inflammation, symptoms, lung function and reliever use in people with asthma. This phase IV, open-label, parallel-group, multicentre, exploratory study will enrol 60-80 adult patients with asthma receiving low- or medium-dose inhaled corticosteroids/long-acting β2-agonists (EudraCT identifier number 2018-003467-64). Participants will be randomised 1:1 to either as-needed budesonide/formoterol dry-powder inhaler or salbutamol reliever for 24 weeks, in addition to their maintenance therapy. Daily data will be captured for fractional exhaled nitric oxide, spirometry, asthma symptoms and medication use using devices connected to a smartphone via the STIFLE application. STIFLE will thereby enable not only characterisation of the variability of airway inflammation and clinical outcomes in relation to asthma worsening, but also elucidate the effect of as-needed budesonide/formoterol on airway inflammation against a background of daily maintenance therapy.
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Affiliation(s)
- Tim Harrison
- Nottingham NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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Choy DF, Arron JR. Beyond type 2 cytokines in asthma - new insights from old clinical trials. Expert Opin Ther Targets 2020; 24:463-475. [PMID: 32223656 DOI: 10.1080/14728222.2020.1744567] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Human asthma is a heterogeneous disorder on molecular, pathological, and clinical levels. The paradigm of asthma as an allergic process driven by type 2 cytokines and mediators has led to targeted biologic therapies resulting in some clinical benefit in patient subsets. However, some patient subsets and clinical manifestations do not benefit from these interventions, thus redefining unmet needs. Clinical studies of type 2 directed therapies have identified new targets under investigation in clinical development; these include epithelial alarmins, non-type 2 cytokines, cytokine receptor signaling, mast cells and neuroinflammation.Areas covered: We consider lessons learned concerning asthma pathogenesis from observational studies and clinical trials of biologic agents that target type 2 mediators. We also provide a perspective on emerging therapeutic hypotheses to target processes independent of or orthogonal to type 2 inflammation in asthma.Expert opinion: Type 2 inflammation is continuous, not discrete, and is likely a modifier of underlying dysregulated airway physiology. Non-type 2 inflammatory mediators (e.g., IL17, IL6, IFNs), microbiome, alarmins (e.g., TSLP, IL33), mast cells and sensory neurons may represent orthogonal targets to type 2 mediators. There is a need to better match targets and outcome measures in biologically defined patient populations to appropriately test hypotheses in the clinic.
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Siddiqui S, Denlinger LC, Fowler SJ, Akuthota P, Shaw DE, Heaney LG, Brown L, Castro M, Winders TA, Kraft M, Wagers S, Peters MC, Pavord ID, Walker S, Jarjour NN. Unmet Needs in Severe Asthma Subtyping and Precision Medicine Trials. Bridging Clinical and Patient Perspectives. Am J Respir Crit Care Med 2020; 199:823-829. [PMID: 30726120 DOI: 10.1164/rccm.201809-1817pp] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Salman Siddiqui
- 1 National Institute for Health Research (NIHR) Respiratory Biomedical Research Centre, College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Loren C Denlinger
- 2 Allergy, Pulmonary, and Critical Care Division, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Stephen J Fowler
- 3 Division of Infection, Immunity, and Respiratory Medicine, School of Biological Sciences, The University of Manchester and NIHR Biomedical Research Centre, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Praveen Akuthota
- 4 Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, California
| | - Dominick E Shaw
- 5 NIHR Biomedical Research Centre, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Liam G Heaney
- 6 Centre for Experimental Medicine, Queens University Belfast, Belfast, United Kingdom
| | - Louise Brown
- 7 Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Mario Castro
- 8 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Tonya A Winders
- 9 Allergy and Asthma Network, Global Allergy and Asthma Patient Platform, Vienna, Austria
| | - Monica Kraft
- 10 Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | | | - Michael C Peters
- 12 Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Ian D Pavord
- 13 Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; and
| | - Samantha Walker
- 14 Asthma UK and Edinburgh University, Edinburgh, United Kingdom
| | - Nizar N Jarjour
- 2 Allergy, Pulmonary, and Critical Care Division, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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Eriksson G, Nolte H, Ljørring C, Riis B, Virchow JC. Comparison of the novel CompEx asthma exacerbation endpoint to the ATS/ERS adapted moderate/severe asthma exacerbation definition used in the MITRA trial. Respir Med 2019; 153:1-2. [PMID: 31136926 DOI: 10.1016/j.rmed.2019.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/09/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Göran Eriksson
- Department of Respiratory Medicine and Allergology, Lund University Hospital, Lund, Sweden
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Sullivan PW, Ghushchyan VH, Marvel J, Barrett YC, Fuhlbrigge AL. Association Between Pulmonary Function and Asthma Symptoms. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2319-2325. [PMID: 31034996 DOI: 10.1016/j.jaip.2019.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/19/2019] [Accepted: 04/09/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND FEV1 as a percentage of predicted (FEV1%pred) is commonly measured in asthma clinical studies; however, reports vary on its association with asthma control instruments evaluating symptoms. OBJECTIVE Assess the association between FEV1%pred and Asthma Control Questionnaire (ACQ) scores in a managed-care population with persistent asthma. METHODS Retrospective analysis of survey responses and spirometry results of patients (aged ≥12 years) with persistent asthma from the Observational Study of Asthma Control and Outcomes was done. Eligible patients received 4 identical surveys including the 5-item ACQ (ACQ-5)/6-item ACQ (ACQ-6) and completed spirometry in parallel. Longitudinal analyses, comparisons of change over time, and fixed- and random-effects regression analyses were conducted, with/without adjustment for covariates. RESULTS There were 1748 survey responses with valid spirometry results. In unadjusted models, coefficients for ACQ-5/ACQ-6 scores were not statistically significant and coefficient of determination (R2) was low (0.03). When adjusted for covariates, ACQ-5 and ACQ-6 scores were significantly associated with FEV1%pred (P < .001) and R2 increased to 0.11 and 0.12, respectively. In adjusted models, every 1-point increase in ACQ-5 and ACQ-6 scores was associated with a 1.7% and 1.9% decrease, respectively, in FEV1%pred. Change in FEV1%pred and change in ACQ-5/ACQ-6 scores were not significantly associated in regressions with/without covariates. CONCLUSIONS The weak and statistically insignificant association between FEV1%pred and ACQ-5/ACQ-6 scores in unadjusted models suggests a high degree of unexplained variation between these measures. Results support the use of both symptoms and pulmonary function, rather than relying on one measure alone, to assess asthma control in clinical care and outcomes studies.
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Affiliation(s)
| | - Vahram H Ghushchyan
- Center for Pharmaceutical Outcomes Research, University of Colorado, Aurora, Colo; American University of Armenia, Yerevan, Armenia
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FitzGerald JM, Sadatsafavi M. Improving precision in the prediction of asthma exacerbations. THE LANCET RESPIRATORY MEDICINE 2017; 5:539-540. [PMID: 28583394 DOI: 10.1016/s2213-2600(17)30212-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 10/19/2022]
Affiliation(s)
- J Mark FitzGerald
- Respiratory Evaluation Service Program, Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; The Lung Centre, Vancouver, BC V5Z1M9, Canada.
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Service Program, Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
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