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Petkovic K, Strika Z, Likic R, Lucijanic M. Spotlight commentary: Integrating artificial intelligence in clinical pharmacology: Opportunities, challenges and ethical imperatives. Br J Clin Pharmacol 2024. [PMID: 39235139 DOI: 10.1111/bcp.16241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 08/13/2024] [Accepted: 08/24/2024] [Indexed: 09/06/2024] Open
Affiliation(s)
- Karlo Petkovic
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Zdeslav Strika
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Robert Likic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Internal Medicine, Unit for Clinical Pharmacology, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - Marko Lucijanic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Internal Medicine, Unit for Hematology, University Hospital Dubrava, Zagreb, Croatia
- Department of Scientific Research and Translational Medicine, University Hospital Dubrava, Zagreb, Croatia
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Garcia G, van Dijkman SC, Pavord I, Singh D, Oosterholt S, Fulmali S, Majumdar A, Della Pasqua O. A Simulation Study of the Effect of Clinical Characteristics and Treatment Choice on Reliever Medication Use, Symptom Control and Exacerbation Risk in Moderate-Severe Asthma. Adv Ther 2024; 41:3196-3216. [PMID: 38916810 PMCID: PMC11263416 DOI: 10.1007/s12325-024-02914-w] [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: 04/29/2024] [Accepted: 05/29/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION The relationship between immediate symptom control, reliever medication use and exacerbation risk on treatment response and factors that modify it have not been assessed in an integrated manner. Here we apply simulation scenarios to evaluate the effect of individual baseline characteristics on treatment response in patients with moderate-severe asthma on regular maintenance dosing monotherapy with fluticasone propionate (FP) or combination therapy with fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR). METHODS Reduction in reliever medication use (puffs/24 h), change in symptom control scores (ACQ-5), and annualised exacerbation rate over 12 months were simulated in a cohort of patients with different baseline characteristics (e.g. time since diagnosis, asthma control questionnaire (ACQ-5) symptom score, smoking status, body mass index (BMI) and sex) using drug-disease models derived from large phase III/IV clinical studies. RESULTS Simulation scenarios show that being a smoker, having higher baseline ACQ-5 and BMI, and long asthma history is associated with increased reliever medication use (p < 0.01). This increase correlates with a higher exacerbation risk and higher ACQ-5 scores over the course of treatment, irrespective of the underlying maintenance therapy. Switching non-responders to ICS monotherapy to combination therapy after 3 months resulted in immediate reduction in reliever medication use (i.e. 1.3 vs. 1.0 puffs/24 h for FP/SAL and BUD/FOR, respectively). In addition, switching patients with ACQ-5 > 1.5 at baseline to FP/SAL resulted in 34% less exacerbations than those receiving regular dosing BUD/FOR (p < 0.01). CONCLUSIONS We have identified baseline characteristics of patients with moderate to severe asthma that are associated with greater reliever medication use, poor symptom control and higher exacerbation risk. Moreover, the effects of different inhaled corticosteroid (ICS)/long-acting beta agonist (LABA) combinations vary significantly when considering long-term treatment performance. These factors should be considered in clinical practice as a basis for personalised management of patients with moderate-severe asthma symptoms.
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Affiliation(s)
| | - Sven C van Dijkman
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK
| | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dave Singh
- University of Manchester, Manchester University NHS Foundations Trust, Manchester, UK
| | - Sean Oosterholt
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK
| | - Sourabh Fulmali
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Anurita Majumdar
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK.
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK.
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Sethi V, Qin L, Cox E, Trocóniz IF, Della Pasqua O. Model-Based Meta-Analysis Supporting the Combination of Acetaminophen and Topical Diclofenac in Acute Pain: A Therapy for Mild-to-Moderate Osteoarthritis Pain? Pain Ther 2024; 13:145-159. [PMID: 38183573 PMCID: PMC10796861 DOI: 10.1007/s40122-023-00569-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/16/2023] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION Acetaminophen and topical diclofenac (AtopD) have complementary mechanisms of action and are therefore candidates for combination use in osteoarthritis (OA) pain. However, an evidence gap exists on their combination use in OA pain. This study aimed to assess the effects of this combination and compare its performance relative to monotherapies on pain score reduction and opioid-sparing effect by leveraging evidence from acute pain setting using a model-based meta-analysis (MBMA). METHODS A literature search was conducted using the MEDLINE database to identify randomized controlled trials (RCTs) studying the combination for acute pain. Subsequently, an MBMA of RCTs was implemented in conjunction with extrapolation principles to infer efficacy in the population of interest. Pain score reduction and opioid-sparing effect (OSE) were selected as the measures of efficacy. RESULTS A total of 11 RCTs encompassing 1396 patients were included. Exploratory evaluation revealed AtopD combination to show greater pain score reduction versus acetaminophen monotherapy. However, pain score reduction was more susceptible to confounding by opioid patient-controlled analgesia (PCA) than OSE. Therefore, a parsimonious MBMA evaluating OSE was developed from 5 of the 11 RCTs (n = 353 patients). The analysis revealed a statistically significant interaction coefficient, suggesting a reduction of 32% in opioid use with the combination versus acetaminophen monotherapy. Differences in the effect size of the combination were less conclusive versus diclofenac monotherapy. CONCLUSION Our results indicate greater pain reduction and opioid-sparing efficacy for the AtopD combination versus acetaminophen monotherapy. Given the similar pain pathways and mechanisms of action of the two drugs in acute and mild-to-moderate OA pain, comparable beneficial effects from the combination therapy may be anticipated following extrapolation to chronic OA pain. Prospective RCTs and real-world studies in OA pain are needed to confirm the differences in the efficacy of the combination treatment observed in our study.
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Affiliation(s)
- Vidhu Sethi
- Medical Affairs, Haleon (Formerly GSK Consumer Healthcare), GSK Asia House, Rochester Park, Singapore, 139234, Singapore
| | - Li Qin
- Quantitative Science, Certara, Princeton, USA
| | - Eugène Cox
- Quantitative Science, Certara, Princeton, USA
| | - Iñaki F Trocóniz
- Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, BMA House, Tavistock Square, London, WC1H 9JP, UK.
- Clinical Pharmacology Modelling and Simulation, GlaxoSmithKline, Brentford, UK.
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Oosterholt S, Pavord ID, Brusselle G, Yorgancıoğlu A, Pitrez PM, Pg A, Teli C, Della Pasqua O. Modelling ASthma TrEatment Responses (MASTER): Effect of individual patient characteristics on the risk of exacerbation in moderate or severe asthma: A time-to-event analysis of randomized clinical trials. Br J Clin Pharmacol 2023; 89:3273-3290. [PMID: 37221636 DOI: 10.1111/bcp.15801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/05/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023] Open
Abstract
AIMS There is limited understanding of how clinical and demographic characteristics are associated with exacerbation risk in patients with moderate-to-severe asthma, and how these factors correlate with symptom control and treatment response. Here we assess the relationship between baseline characteristics and exacerbation risk during regular dosing with inhaled corticosteroids (ICS) monotherapy or in combination with long-acting beta2-agonists (ICS/LABA) in clinical trial patients with varying levels of symptom control, as assessed by the asthma control questionnaire (ACQ-5). METHODS A time-to-event model was developed using pooled patient data (N = 16 282) from nine clinical studies [Correction added on 26 July 2023, after first online publication: The N value in the preceding sentence has been corrected in this version.]. A parametric hazard function was used to describe the time-to-first exacerbation. Covariate analysis included the assessment of the effect of seasonal variation, clinical and demographic baseline characteristics on baseline hazard. Predictive performance was evaluated by standard graphical and statistical methods. RESULTS An exponential hazard model best described the time-to-first exacerbation in moderate-to-severe asthma patients. Body mass index, smoking status, sex, ACQ-5, % predicted forced expiratory volume over 1 s (FEV1 p) and season were identified as statistically significant covariates affecting baseline hazard irrespective of ICS or ICS/LABA use. Fluticasone propionate/salmeterol (FP/SAL) combination therapy resulted in a significant reduction in the baseline hazard (30.8%) relative to FP monotherapy. CONCLUSIONS Interindividual differences at baseline and seasonal variation affect the exacerbation risk independently from drug treatment. Moreover, it appears that even when a comparable level of symptom control is achieved in a group of patients, each individual may have a different exacerbation risk, depending on their baseline characteristics and time of the year. These findings highlight the importance of personalized interventions in moderate-to-severe asthma patients.
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Affiliation(s)
- Sean Oosterholt
- Clinical Pharmacology Modelling and Simulation, GSK, London, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and NIHR Respiratory BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | | | | | - Abhijith Pg
- Global Classic and Established Medicines, GSK, Singapore, Singapore
| | - Chirag Teli
- Global Classic and Established Medicines, GSK, Mumbai, India
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling and Simulation, GSK, London, UK
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK
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Singh D, Oosterholt S, Pavord I, Garcia G, Abhijith Pg, Della Pasqua O. Understanding the Clinical Implications of Individual Patient Characteristics and Treatment Choice on the Risk of Exacerbation in Asthma Patients with Moderate-Severe Symptoms. Adv Ther 2023; 40:4606-4625. [PMID: 37589831 PMCID: PMC10499702 DOI: 10.1007/s12325-023-02590-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/21/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION The assessment of future risk has become an important feature in the management of patients with asthma. However, the contribution of patient-specific characteristics and treatment choices to the risk of exacerbation is poorly understood. Here we evaluated the effect of interindividual baseline differences on the risk of exacerbation and treatment performance in patients receiving regular maintenance doses of inhaled corticosteroids (ICS) or ICS/long-acting beta-agonists (LABA) combination therapy. METHODS Exacerbations and changes to asthma symptoms 5-item Asthma Control Questionnaire (ACQ-5) were simulated over a 12-month period using a time-to-event and a longitudinal model developed from phase III/IV studies in patients with moderate-severe asthma (N = 16,282). Simulations were implemented to explore treatment performance across different scenarios, including randomised designs and real-world settings. Treatment options included regular dosing with ICS monotherapy [fluticasone propionate (FP)] and combination therapy [fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR)]. Exacerbation rate was analysed using the log-rank test. The cumulative incidence of events was summarised stratified by treatment. RESULTS Being a woman, smoker, having higher baseline ACQ-5 and body mass index (BMI) and lower forced expiratory volume in the first second (FEV1) are associated with increased exacerbation risk (p < 0.01). This risk is bigger in winter because of the seasonal variation effect. Across the different scenarios, the use of FP/SAL resulted in a 10% lower annual incidence of exacerbations relative to FP or regular dosing BUD/FOR, independently of baseline characteristics. Similar differences in the annual incidence of exacerbations were also observed between treatments in obese patients (BMI ≥ 25-35 kg/m2) (p < 0.01) and in patients who do not achieve symptom control on FP monotherapy. CONCLUSIONS Individual baseline characteristics and treatment choices affect future risk. Achieving comparable levels of symptom control whilst on treatment does not imply comparable risk reduction, as shown by the lower exacerbation rates in FP/SAL vs. BUD/FOR-treated patients. These factors should be considered as a basis for personalised clinical management of patients with moderate-severe asthma.
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Affiliation(s)
- Dave Singh
- University of Manchester, Manchester University NHS Foundations Trust, Manchester, UK
| | - Sean Oosterholt
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK
| | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gabriel Garcia
- Respiratory Medicine Service, Rossi Hospital, La Plata, Argentina
| | - Abhijith Pg
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling and Simulation, GSK, GSK House, 980 Great West Rd, London, TW8 9GS, UK.
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK.
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Müderrisoglu AE, de la Rosette JJMCH, Michel MC. Potential side effects of currently available pharmacotherapies in male lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Expert Opin Drug Saf 2023; 22:1213-1224. [PMID: 38064204 DOI: 10.1080/14740338.2023.2293206] [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: 07/31/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION The drug classes of α1-adrenoceptor antagonists, 5α-reductase inhibitors, and phosphodiesterase type 5 inhibitors are guideline-recommended treatments of lower urinary tract symptoms suggestive of benign prostatic hyperplasia; muscarinic receptor antagonists and β3-adrenoceptor agonists are also recommended if storage symptoms are insufficiently addressed with one of the other three drug classes. AREAS COVERED We provide a narrative review (no formalized literature searches performed) of the tolerability of these drug classes with emphasis on the more recently introduced medications, on combination treatment, and on more lately emerging risks. EXPERT OPINION/COMMENTARY The tolerability profiles are distinct between drug classes but, with few exceptions, similar within a drug class. Within a drug, formulations with longer duration of action tend to have better tolerability. Efficacy gains using combination treatment at least partly come at a cost of lesser tolerability. Greater susceptibility to experience adverse events based on age, comorbidities, and comedications appears conceptually important but remains under-investigated in this therapeutic area.
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Affiliation(s)
- A Elif Müderrisoglu
- Department of Medical Pharmacology, Istanbul Medipol University, Istanbul, Turkiye
| | | | - Martin C Michel
- Department of Pharmacology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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Chan P, Peskov K, Song X. Applications of Model-Based Meta-Analysis in Drug Development. Pharm Res 2022; 39:1761-1777. [PMID: 35174432 PMCID: PMC9314311 DOI: 10.1007/s11095-022-03201-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/11/2022] [Indexed: 12/13/2022]
Abstract
Model-based meta-analysis (MBMA) is a quantitative approach that leverages published summary data along with internal data and can be applied to inform key drug development decisions, including the benefit-risk assessment of a treatment under investigation. These risk-benefit assessments may involve determining an optimal dose compared against historic external comparators of a particular disease indication. MBMA can provide a flexible framework for interpreting aggregated data from historic reference studies and therefore should be a standard tool for the model-informed drug development (MIDD) framework.In addition to pairwise and network meta-analyses, MBMA provides further contributions in the quantitative approaches with its ability to incorporate longitudinal data and the pharmacologic concept of dose-response relationship, as well as to combine individual- and summary-level data and routinely incorporate covariates in the analysis.A common application of MBMA is the selection of optimal dose and dosing regimen of the internal investigational molecule to evaluate external benchmarking and to support comparator selection. Two case studies provided examples in applications of MBMA in biologics (durvalumab + tremelimumab for safety) and small molecule (fenebrutinib for efficacy) to support drug development decision-making in two different but well-studied disease areas, i.e., oncology and rheumatoid arthritis, respectively.Important to the future directions of MBMA include additional recognition and engagement from drug development stakeholders for the MBMA approach, stronger collaboration between pharmacometrics and statistics, expanded data access, and the use of machine learning for database building. Timely, cost-effective, and successful application of MBMA should be part of providing an integrated view of MIDD.
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Affiliation(s)
- Phyllis Chan
- Clinical Pharmacology, Genentech, 1 DNA Way, South San Francisco, CA, 94080, USA.
| | - Kirill Peskov
- M&S Decisions LLC, Moscow, Russia
- Sechenov First Moscow State Medical University, Moscow, Russia
- STU 'Sirius', Sochi, Russia
| | - Xuyang Song
- Clinical Pharmacology and Quantitative Pharmacology, AstraZeneca, 1 Medimmune Way, Gaithersburg, MD, 20878, USA
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Borella E, Oosterholt S, Magni P, Pasqua OD. Characterisation of individual ferritin response in patients receiving chelation therapy. Br J Clin Pharmacol 2022; 88:3683-3694. [PMID: 35199367 PMCID: PMC9544664 DOI: 10.1111/bcp.15290] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/21/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022] Open
Abstract
Aims To develop a drug–disease model describing iron overload and its effect on ferritin response in patients affected by transfusion‐dependent haemoglobinopathies and investigate the contribution of interindividual differences in demographic and clinical factors on chelation therapy with deferiprone or deferasirox. Methods Individual and mean serum ferritin data were retrieved from 13 published studies in patients affected by haemoglobinopathies receiving deferiprone or deferasirox. A nonlinear mixed effects modelling approach was used to characterise iron homeostasis and serum ferritin production taking into account annual blood consumption, baseline demographic and clinical characteristics. The effect of chelation therapy was parameterised as an increase in the iron elimination rate. Internal and external validation procedures were used to assess model performance across different study populations. Results An indirect response model was identified, including baseline ferritin concentrations and annual blood consumption as covariates. The effect of chelation on iron elimination rate was characterised by a linear function, with different slopes for each drug (0.0109 [90% CI: 0.0079–0.0131] vs. 0.0013 [90% CI: 0.0008–0.0018] L/mg mo). In addition to drug‐specific differences in the magnitude of the ferritin response, simulation scenarios indicate that ferritin elimination rates depend on ferritin concentrations at baseline. Conclusion Modelling of serum ferritin following chronic blood transfusion enabled the evaluation of drug‐induced changes in iron elimination rate and ferritin production. The use of a semi‐mechanistic parameterisation allowed us to disentangle disease‐specific factors from drug‐specific properties. Despite comparable chelation mechanisms, deferiprone appears to have a significantly larger effect on the iron elimination rate than deferasirox.
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Affiliation(s)
- Elisa Borella
- Department of Industrial Engineering and Informatics, Università degli Studi di Pavia, Pavia, Italy
| | - Sean Oosterholt
- Clinical Pharmacology & Therapeutics Group, University College London, London, United Kingdom
| | - Paolo Magni
- Department of Industrial Engineering and Informatics, Università degli Studi di Pavia, Pavia, Italy
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, London, United Kingdom.,Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Brentford, United Kingdom
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D'Agate S, Chavan C, Manyak M, Palacios‐Moreno JM, Oelke M, Michel MC, Roehrborn CG, Della Pasqua O. Model-based meta-analysis of the time to first acute urinary retention or benign prostatic hyperplasia-related surgery in patients with moderate or severe symptoms. Br J Clin Pharmacol 2021; 87:2777-2789. [PMID: 33247951 PMCID: PMC8359386 DOI: 10.1111/bcp.14682] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/27/2020] [Accepted: 11/15/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS Combination therapy of 5α-reductase inhibitor and α-blocker is a guideline-endorsed therapeutic approach for patients with moderate-to-severe lower urinary tract symptoms or benign prostatic hyperplasia (LUTS/BPH) who are at risk of disease progression. We aimed to disentangle the contribution of clinical and demographic baseline characteristics affecting the risk of acute urinary retention or BPH-related surgery (AUR/S) from the effect of treatment with drugs showing symptomatic and disease-modifying properties. METHODS A time-to-event model was developed using pooled data from patients (n = 10 238) enrolled into six clinical studies receiving placebo, tamsulosin, dutasteride or tamsulosin-dutasteride combination therapy. A parametric hazard function was used to describe the time to first AUR/S. Covariate model building included the assessment of relevant clinical and demographic factors on baseline hazard. Predictive performance was evaluated by graphical and statistical methods. RESULTS An exponential hazard model best described the time to first AUR/S in this group of patients. Baseline International Prostate Symptom Score, prostate-specific antigen, prostate volume and maximum urine flow were identified as covariates with hazard ratio estimates of 1.04, 1.08, 1.01 and 0.91, respectively. Dutasteride monotherapy and tamsulosin-dutasteride combination therapy resulted in a significant reduction in the baseline hazard (56.8% and 66.4%, respectively). By contrast, the effect of tamsulosin did not differ from placebo. CONCLUSIONS Our analysis showed the implications of disease-modifying properties of dutasteride and tamsulosin-dutasteride combination therapy for the risk of AUR/S. It also elucidated the contribution of different baseline characteristics to the risk of these events. The use of tamsulosin monotherapy (symptomatic treatment) has no impact on individual long-term risk.
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Affiliation(s)
- Salvatore D'Agate
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonWC1H 9JPUK
| | | | - Michael Manyak
- Global Medical UrologyGlaxoSmithKlinePhiladelphiaPA19112USA
| | | | - Matthias Oelke
- Department of UrologySt Antonius HospitalGronauD‐48599Germany
| | - Martin C. Michel
- Department of PharmacologyJohannes Gutenberg UniversityMainz55131Germany
| | | | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonWC1H 9JPUK
- Clinical Pharmacology Modelling & SimulationGSK HouseLondonTW8 9GSUK
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Impact of early vs. delayed initiation of dutasteride/tamsulosin combination therapy on the risk of acute urinary retention or BPH-related surgery in LUTS/BPH patients with moderate-to-severe symptoms at risk of disease progression. World J Urol 2020; 39:2635-2643. [PMID: 33337513 PMCID: PMC8332595 DOI: 10.1007/s00345-020-03517-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/30/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate the effect of delayed start of combination therapy (CT) with dutasteride 0.5 mg and tamsulosin 0.4 mg on the risk of acute urinary retention or benign prostatic hyperplasia (BPH)-related surgery (AUR/S) in patients with moderate-to-severe lower urinary tract symptoms (LUTS) at risk of disease progression. Methods Using a time-to-event model based on pooled data from 10,238 patients from Phase III/IV dutasteride trials, clinical trial simulations (CTS) were performed to assess the risk of AUR/S up to 48 months in moderate-to-severe LUTS/BPH patients following immediate and delayed start of CT for those not responding to tamsulosin monotherapy. Simulation scenarios (1300 subjects/arm) were investigated, including immediate start (reference) and alternative delayed start (six scenarios 1–24 months). AUR/S incidence was described by Kaplan–Meier survival curves and analysed using log-rank test. The cumulative incidence of events as well as the relative and attributable risks were summarised stratified by treatment. Results Survival curves for patients starting CT at month 1 and 3 did not differ from those who initiated CT immediately. By contrast, significant differences (p < 0.001) were observed when switch to CT occurs ≥ 6 months from the initial treatment. At month 48, AUR/S incidence was 4.6% vs 9.5%, 11.0% and 11.3% in patients receiving immediate CT vs. switchers after 6, 12 and 24 months, respectively. Conclusions Start of CT before month 6 appears to significantly reduce the risk of AUR/S compared with delayed start by ≥ 6 months. This has implications for the treatment algorithm for men with LUTS/BPH at risk of disease progression. Electronic supplementary material The online version of this article (10.1007/s00345-020-03517-0) contains supplementary material, which is available to authorized users.
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